Health inspection·December 3, 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 observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 3 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's baclofen (muscle relaxant) was administered as ordered on 10/23/2025 and 10/24/2025. This failure could place the residents at risk of not having medications available for use and medications errors.Findings included: Record review of Resident #1's face sheet dated 10/30/2025 indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included spinal stenosis (narrowing of the spinal canal with can lead to compression of the nerves and cause low back pain and discomfort), dementia (deterioration of memory, language, and other thinking abilities) and chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated he understood others and was understood by others. Resident #1's MDS assessment indicated he had a BIMS score of 14, which indicated his cognition was intact. The MDS assessment indicated Resident #1 was independent for eating and hygiene and required supervision for bathing. The MDS assessment indicated Resident #1 received scheduled and as needed pain medication. Record review of Resident #1's care plan revised 09/11/2025, indicated he had a diagnosis of muscle spasms, abnormal muscle movement and was at risk for adverse reactions to medication. Interventions included providing medications as ordered. Record review of Resident #1's Order Summary Report dated 10/30/2025 indicated he had an order for baclofen 5 mg give 1 tablet orally three times a day with a start date of 04/11/2025. Record review of Resident #1's October 2025 MAR indicated baclofen 1 tablet orally three times a day at 7 AM, 1 PM, and 7:00 PM. Resident #1's MAR indicated the baclofen was not administered on: 10/23/2025 at 1 PM. 10/24/2025 at 7 AM, 1 PM, and 7:00 PM. Record review of Resident #1's progress notes indicated: 10/23/2025, Baclofen 5 mg pending arrival from pharmacy, signed by LVN A. 10/24/2025, Baclofen 5 mg pending arrival from pharmacy, signed by LVN A. During an interview on 10/30/2025 at 9:34 AM, Resident #1 said around the middle of this month (October 2025), his baclofen was not administered two days. Resident #1 said LVN A told him his medication ran out, and she had called it in. LVN A said it was not delivered because the pharmacy said it was too early to fill it. Resident #1 said LVN A told him she could not administer it from the emergency medication kit because it did not contain it. During an interview on 10/30/2025 at 11:32 AM, LVN A said sometimes the residents' medications ran out. LVN A said if they did not have a resident's medication, they checked the emergency medications to see if it was available for administration, if it was not available, the residents did not receive their medication. LVN A said if they did not have a resident's medication Page 1 of 2 675037 675037 12/03/2025 Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few they should contact the pharmacy, notify the DON and doctor. LVN A said Resident #1 ran out of his baclofen the previous week, and he did not receive it for maybe one day. LVN A said she had not notified the doctor because he did not miss that many doses. LVN A said if she did not administer the baclofen, it was because it was not in the emergency medications. LVN A said she had contacted the pharmacy and notified the DON Resident #1 did not have any baclofen for administration, and she had administered it when it was delivered. LVN A said Resident #1 did not suffer any side effects from not receiving the baclofen, and he had as needed pain medications that could be administered if he needed them. LVN A said it was important to administer medications as ordered to help manage the residents' conditions. During an observation and interview on 10/30/2025 at 2:43 PM, an observation of the emergency medications was made with the DON, and there were only baclofen 10 mg tablets available. The DON said earlier in the month Resident #1 had notified her he had not received his baclofen. The DON said she called the pharmacy, and they told her they had delivered a supply for one month earlier in the month. The DON said the nurses received the medications from the pharmacy, and the nurses were supposed to verify the amount received when they signed for the medications. The DON said she searched everywhere in the facility for the baclofen and did not find it. The DON said she called the pharmacy, notified them, and they sent the medication to the facility on [DATE]. The DON said the nurses did not notify her Resident #1 did not have any baclofen and they had not administered it. The DON said she found out about the baclofen when Resident #1 notified her. The DON said if the nurses would have notified her, they could have called the pharmacy to see if they could cut the 10 mg baclofen tablet in half to administer it to Resident #1. The DON said every morning they had a clinical meeting, and she pulled reports to see if any residents did not receive their medications. The DON said she did not catch that Resident #1 did not receive his baclofen as ordered. The DON said depending on the medication that was not administered, not administering medications could potentially cause an exacerbation of the residents' disease processes. During an interview on 10/30/2025 at 2:56 PM, a Pharmacy Technician with the facility's pharmacy indicated the DON called in a refill for Resident #1's baclofen on 10/24/25 and it was delivered 10/25/2025. The Pharmacy Technician said on 10/03/2025 the pharmacy delivered 90 tablets of baclofen 5 mg, which would have been a 30-day supply. The Pharmacy Technician said Resident #1 ran out of his medication approximately 4-5 days early. During an interview on 10/20/2025 at 4:26 PM, the Administrator said she was not aware of the doses of baclofen Resident #1 did not receive. The Administrator said she was notified by the DON Resident #1 did not have any baclofen, and the DON had ordered it and was going to have it delivered. The Administrator said her expectations were if the nurses had a medication that was not available, they should immediately notify the DON or her so they could call the pharmacy, have it delivered, and have the medication administered to the resident by their next scheduled dose. The Administrator said it was important for them to have the residents' medications available for administration to ensure the residents received the medications the doctor had prescribed. Record review of a pharmacy delivery receipt dated 10/03/2025 indicated 90 tablets of Baclofen 5 mg were delivered to the facility for Resident #1. Record review of the facility's policy titled, Administering Medications, revised April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders. 675037 Page 2 of 2