Health inspection·December 22, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for one (Resident #1) reviewed for medications.The facility failed to document the receipt and disposition Resident #1's Oxycodone HCI medication.This failure could result in controlled medications not accurately and periodically reconciled.Findings included:Record review of Resident #1's face sheet reflected a [AGE] year-old female with diagnoses which included chronic diastolic (congestive) heart failure, essential (primary) hypertension, and generalized muscle weakness. Resident #1 also had diagnoses for pain in both the right and left knees, along with other chronic pain issues, highlighting a potential need for effective pain management.A record review of Resident #1's medication administration record (MAR), dated 12/22/2025, reflected on 11/20/2025, Resident #1 was ordered Oxycodone HCl oral tablets, 5 mg, to be administered as needed for pain every 12 hours. The MAR reflected this medication was discontinued as of 11/18/2025.Record review of Resident # 1's progress notes, dated 12/4/2025, reflected she was discharged home with all personal belongings and prescriptions. The staff reviewed the medication orders with her, and she understood the list provided. Notably, the patient refused to take her PRN oxycodone and was picked up by a family member in a private vehicle. In an interview on 12/22/2025 at 2:08 PM, RN A stated if medications were left behind by discharged residents, they should be signed for and documented by the Director of Nursing (DON).In an interview on 12/22/2025 at 2:11 PM, RN B indicated all narcotics and discharge records were managed by the DON and must be logged, with non-narcotic medications stored separately.In an interview on 12/22/2025 at 2:15 PM, LVN A noted any medications left with him would be reported to the DON immediately for tracking and logging, emphasizing all tracking required two staff signatures.In an interview on 12/22/2025, at 2:35 PM, Medication Aide A explained her protocol for disposing of medications left by discharging residents, which included removing the blister pack and bringing the pills to the DON for proper disposal.Observation on 12/22/2025 at 3:54 PM of the medication storage room revealed the facility did not utilize written logs, only an electronic deviceIn an interview on 12/22/2025 at 3:55 PM, LVN A stated while all narcotic drugs required two staff members for sign-out, the process differed for discharged patients, with the understanding that drugs left behind should be logged by the DON.An attempted interview by telephone with Resident #1 at 4:33 PM was unsuccessful. A voicemail was left and a return call was requested.In an interview at 4:45 PM, the DON stated the issue surrounding the undocumented oxycodone and stated she could not provide a log for medications left behind by residents. The DON stated she recognized this as a serious problem and was committed to working with her staff to rectify the situation.Record review on Google.com at 4:06 PM reflects that BD Pyxis™ MedBank™ is designed to enhance safe storage, dispensing, and tracking of medications, which aims to improve patient safety and operational efficiency in medication management.Record review of the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455917 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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)