Health inspection·April 8, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to self-administer medications if the interdisciplinary team determined that this practice was clinically appropriate for 1 of 5 resident (Resident #12) reviewed for medication self-administration. Residents Affected - Some The facility did not assess Resident #12 for self-administration safety. This failure could place residents at risk for not receiving medication as ordered and ingesting an incorrect amount of medication. Findings include: Record review of Resident #12's admission MDS, dated [DATE], and revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included cancer, arthritis (joint inflammation), Alzheimer's disease (a disease that destroys memory and other mental functions), and rheumatoid arthritis (inflammatory disorder affecting joints). Her BIMS is 11. Scores between 0-7 indicate severe cognitive impairment, scores between 8 and 12 indicate moderate impairment, while scores above 13 indicate little to no impairment. Record review of Resident #12's Order Summary Report revealed an order for 10ml of Storm Wash (liquid oral medication used for sores in mouth and throat) for mouth before meals and at bedtime for throat cancer. Swish and swallow 10ml 5 minutes before meals and at bedtime. The start date for the medication was 03/29/2025 with no end date. Record review of Resident #12's Care Plan, dated 03/29/2025, did not indicate that self-administration of medications was care planned. In addition, the care plan did not address the medication. No documentation in the care plan was found regarding the medication. Record review of Resident #12's assessments and progress notes, dated from 03/28/2025 to 04/07/2025, did not reveal the resident had been instructed in the proper use of the bedside medication, which included demonstrating appropriate use of the medication, and documentation of this education in the medical record. Observations on 04/06/2025 at 9:30 AM revealed two unsecured prescription bottles of [NAME] Wash on Resident #12's nightstand. The label read, [NAME] Wash 1:1:1:1, swish and swallow 10 ml 5 minutes before meals and at bedtime. No medication measuring cups were noted in the room and no locked boxes or locked drawers were observed. (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 5 Event ID: 675042 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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)