Health inspection·December 10, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1 capsule by mouth two times a day for Pain management, pending delivery. Further review revealed LVN A wrote the progress note for 10/15/25. Observation and interview on 10/14/25 at 1:22 PM Resident #1 was sitting on his bed. Resident #1 stated he often had pain related to swelling to the side of his face. Resident #1 stated he fell earlier this year in the bathroom, and his back would hurt, and he had a hernia that often caused a lot of pain. Resident #1 stated he received pain medications, but he had to beg for them, he had to keep asking staff for the medications. He stated the medications helped. Interview on 10/15/25 at 5PM the ADON revealed nursing staff should re-order a medication at least 7 days prior to the medication being out. He stated the pharmacy usually delivered medications on the same date or the day after being ordered. The ADON stated nursing staff should have called the pharmacy on 10/11/25 after the request for the refill was placed on 10/10/25 to determine why the medication had not been delivered because it had been days since it was ordered. In addition, nursing staff should let him and the DON know if there were any problems so they could assist with the process as needed. The ADON stated he learned it was not until 10/14/25 that one of the nurse's called for an update. He stated the pharmacy needed a new script for the Lyrica. He stated the same nurse should have also called Resident #1's PCP to obtain a one-time order to dispense the medication from the facility's Pyxus. He stated it had been days since the Lyrica was re-ordered. The ADON stated LVN A should have followed this same process on this date, 10/15/15, especially because Resident #1 had not received the medication in days. He stated LVN A should have called Resident #1's PCP to inform him of the status of the pending delivery so the PCP could provide guidance and make any medication adjustments as needed for the medication. He stated typically the PCP would provide a one-time order for the Lyrica, LVN A would then call the pharmacy to request access to the Pyxus and administer the medication. He stated Resident #1 received Lyrica for pain and stated he also had PRN pain medications for break through pain. However, he further stated there was no reason for Resident #1 to go without the medication which was determined effective for pain management. He stated the fact that nursing staff did not follow the facility's medication administration policy and procedures basically resulted in Resident #1 not receiving the pain medication per physician orders for 5 days. The ADON stated failure to call Resident #1's PCP basically resulted in Resident #1 not receiving his pain medication as ordered. Interview on 10/15/25 at 5:30 PM LVN A revealed the Lyrica order for Resident #1 was still in pending delivery status because the pharmacy had not delivered it. She stated she did not administer Resident #1's morning dose on this date, 10/15/25, and also wrote a progress note, pending delivery. LVN A stated she was provided with agent status (cleared by pharmacy to access Pyxus) to withdraw medications from the Pyxus and stated Lyrica was one of the medications available in the Pyxus. LVN A stated she had not think about obtaining the Lyrica from the Pyxus. She stated she did not call Resident #1's PCP to report Resident #1 had not been receiving the medication as of 10/10/25 or to request a one-time order from the Pyxus. LVN A stated it was necessary to inform Resident #1's PCP of the changes so the PCP could provide guidance and to ensure Resident #1 received the medication per physician orders. She stated as a result Resident #1 pain would not be managed and he could continue to experience pain. Interview on 10/15/25 at 6PM the DON revealed she found out today (10/15/25) there had been a delay in receiving Resident #1's order for Lyrica. She stated nursing staff should re-order medications 10 days before running out. The DON stated if the pharmacy did not deliver the medication within 24 hours, then nursing staff should follow up with a call to determine what was holding the order and take move forward with ensuring the medication was delivered. The DON stated nursing staff should let her and the ADON know when there were any problems so they could assist as needed. She stated anytime a resident did not receive a medication; the charge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455549 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jourdanton Nursing and Rehabilitation 1504 Highway 97e Jourdanton, TX 78026 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete nurse should call the PCP to determine what steps to take to ensure the resident received medications per physician orders. The DON stated the facility had a pyxis and Lyrica was available and there was no reason why he did not receive the medication as ordered. She stated if the charge nurse was not an agent (did not have authorization to dispense medications), she or the ADON could dispense the medication. The DON stated Resident #1 often complained of pain to different areas of his body and there was no excuse why he should be in pain when they had the medication in stock and could easily administer it. The DON stated all nursing staff should follow the policy and procedures for obtaining, dispensing and administering medications, so the residents received the medications per physician orders and in Resident #1's case, so his pain was managed, and he did not experience unnecessary pain. The DON stated Resident #1 had PRN pain medications for break through pain. Review of facility policy, Notification Changes, revised on 5/16/25, read in relevant part The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences or commence a new form of treatment to deal with a problem. Review of facility policy, Medication Reordering, dated 6/15/25, read in relevant part It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services includingthe provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. Pharmaceutical services refers to the process of receiving and interpreting prescriber's orders (e.g., acquiring, receiving, storing, controlling, re-ordering medications, etc.). Acquiring medication is the process by which the facility requests and obtains a medication.Policy Explanation and Compliance Guidelines:1. The facility will utilize a systematic approach to provide or obtain routine and emergency medicationsand biologicals in order to meet the needs of each resident.2. Acquisition of medications should be completed in a timely manner to ensure medications areadministered in a timely manner.3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, thatnurse will reorder the medication, time permitting.4. The nurse that is assigned to each medication cart will perform a medication cross match everyThursday night. (See Medication Cross Match Policy)5. In the event of new orders, the facility is allowed (24) hours to begin a medication unless otherwisespecified by the physician. 6. For stat medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy in a portable, but sealed emergency box or container (may be used if applicable). Event ID: Facility ID: 455549 If continuation sheet Page 3 of 3