Health inspection·November 19, 2025

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it for 1 of 7 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to document review and response to irregularities identified in Resident #1's medication regimen in August and September 2025. This failure could result in unintended effects of medications and/or illness. Findings included: Record review of Resident #1's face sheet dated 10/08/2025 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included intentional self-harm by unspecified firearm discharge and other chronic pain. Record review of Resident #1's quarterly MDS, submitted 8/5/2025, reflected a BIMS score of 15, which indicated intact cognition. Section N0415 reflected Resident #1 was taking opioid medication. Section N2001 (did a complete drug regimen review identify potentially clinically significant medication issues?) was not answered. Record review of a facility document titled All Recommendations dated 8/25/2025 reflected communication from RPh to the facility that read as follows: [Resident #1]Please assess the risk/benefit of the combination of:Buprenorphine 300mcg BIDMethadone 15mg TIDCyclobenzaprine 10mg BIDTizanidine 2mg QHSIn the column of the document labeled follow-through, there was text that read note written to physician in the area next to Resident #1's medication regimen. Record review of a facility document titled All Recommendations dated 9/26/2025 reflected communication from RPh to the facility that read as follows: [Resident #1]CMS Mega Rule Phase II- PRN orders for psychotropic drugs are limited to 14 days . prescriber should document the rationale in the resident's medical record and indicated the duration for the PRN order [sic]Current Medication: Hydroxyzine HCl 25mg every 12 hours PRN for anxiety since 9/22/25In the column of the document labeled follow-through, there was text that read note written to physician in the area next to Resident #1's medication regimen. Record review of Resident #1's progress notes written August and September 2025 did not reveal documentation from a provider indicating review of pharmacy identified regularities had been acknowledged and reviewed. In an interview with the RPh on 10/08/2025 at 12:48 PM, she said she had sent communication to the facility regarding Resident #1's medications in August and September 2025. She said she had documented in her notes a positive response for August 2025, but she could not locate the specific documentation indicating the response from the provider. She said she thought she did not receive a direct response, and it was her process to accept a non-response to indicate that a resident's medication regimen should continue as it was originally ordered. She said she had not received a response from the facility or the provider regarding Resident #1's medication review for September 2025. In an interview with the ADON on 10/9/2025 at 10:30 AM, she said she was the staff member responsible for the medication regimen reviews. She said her process was to send the reviews to the providers immediately after receiving them, and Page 1 of 2 455817 455817 11/19/2025 San Antonio North Nursing and Rehabilitation 501 Ogden San Antonio, TX 78212

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she would receive a response either by e-mail or in person. She said if she does not receive a response, then she does not follow-up with the providers, and the facility will continue the medication regimen as it was ordered. She said the potential harm to residents of not having their medication regimen reviews completed was dependent on the medication, but it could include increased pain or infection. In an interview with the MD on 10/9/2025 at 11:27 AM, he stated he was the physician overseeing the care provided to residents at the facility by the nurse practitioners. He was unaware that Resident #1 had pharmacy recommendation that were unanswered in August and September 2025. He said his expectation was the responsible party will immediately respond to any communication from the pharmacist, and the facility should contact him if they do not receive a timely response. Record review of the facility policy titled Pharmacy Services (revised 6/15/2025) revealed the following:8. The pharmacist, in collaboration with the facility and the medical director, should include within its services to:a. Develop, implement, evaluate and revise (as necessary) the procedures for the provision of all pharmaceutical services, including procedures to support resident quality of life such as those that support safe, individualized medication administration programs . 455817 Page 2 of 2