Inspection·September 28, 2023

F 0755 Interventions: Administer analgesia per orders; Level of Harm - Minimal harm or potential for actual harm Resident #2 was prescribed routine/scheduled pain medication for pain management. Residents Affected - Few Record review of Resident #2's medication administration record (MAR) dated 09/2023 revealed Morphine Sulfate ER tablet extended release 15 Mg. One tablet by mouth two times a day revealed the medication was initial to indicate the medication was administered: PM: 09/20, 09/21, 09/22, 09/23, 09/24, 09/25 and 09/26/2023 AM: 09/21, 09/22, 09/23, 09/24, 09/25, 09/26, and 09/27/2023 Record review of Resident #2's order summary report active orders dated as of 09/27/2023 revealed Morphine sulfate ER tablet extended release 15 Mg. Give one tablet two times a day related to pain. Order dated 09/20/2023. Observation on 09/27/2023 at 7:46 AM during medication administration revealed MA A dispensed Morphine ER 15 Mg tablet in the medication cup. Continued observation at this time revealed the medication container pharmacy directions for administration read Do Not Chew or Crush- Swallow Whole. MA A crushed the medication with a pill crusher. MA A added a spoonful of pudding to the crushed medication in the medication cup. MA A administered the medication to Resident #2. Resident #2 was observed in bed with the head of her bed elevated. Resident #2 swallowed the medication. Interview on 09/27/2023 at 9:15 AM MA A stated she crushed Resident #2's Morphine ER because the resident was on a pureed diet. MA A stated she thought Resident #2 had difficulty swallowing. MA A stated the physician's order Resident #2's medications could be crushed. MA A stated she was unsure how long the medication had been crushed. MA A stated she should have notified the DON the medication had been crushed. MA A stated the DON and ADON monitor medication administration. MA A was not sure how often the medication administrations were monitored. MA A stated the risk of crushing an ER tablet was it could get into the resident's system faster. MA A stated to prevent this in the future the doctor should be notified. The medication should be changed to liquid. Interview on 09/27/2023 at 10:19 AM the DON stated MA A told her she crushed Resident #2's extended-release medication that should not have been crushed. The DON stated the NP and hospice nurse have been notified. The DON stated the order was changed to liquid. The DON stated she did not know how often it was crushed. The DON stated she and the ADON do random medication administration observations. The DON stated the pharmacy consultant also did a medication administration observation. The DON stated the risk of the crushed extended release was the medication becomes instant release. The DON stated MA A should have notified the charge nurse to have the order changed. The DON stated to prevent this from occurring again the nurses and medication aides were all being reeducated. The DON stated the resident sometimes wanted the medications crushed. Interview on 09/27/2023 at 11:03 AM Resident #2 stated she does get the medication crushed in pudding. Resident #2 stated she did not care how she received it. Interview on 09/27/2023 at 11:13 AM the Administrator stated she was notified MA A crushed a medication that should not have been crushed. The Administrator stated she understood the risk was the chemistry of the medication would be changed if crushed. The Administrator stated the crushing could change the effect of the medication. The Administrator stated the medication aides and nurses were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 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 reeducated. Level of Harm - Minimal harm or potential for actual harm Phone interview on 09/28/2023 at 9:33 AM the Facility's Pharmacy Director stated extended release should not be crushed because it was meant to be slow acting and work over an extended time period. The Facility's Pharmacy Director stated when the tablet was crushed it allowed the medications action to be faster and shorter acting. As the interview continued the Pharmacy Director stated labels were on the packages to indicate not to crush or chew. The Pharmacy Director stated he will have the pharmacist do more medication administration observations. Residents Affected - Few Record review of the facility's policy and procedure titled Oral Solid Medication Administration dated 2003 read in part .Some preparations are not meant to be opened or crushed: such as enteric coated, sustained release, and sublingual products. Check with the pharmacy or your drug information text if you question the appropriateness of crushing a medication . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 3 of 3