Health inspection·November 20, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for medication errors.The facility failed to administer Resident #1's glimepiride (an oral medication used to manage blood sugar levels in adults with type 2 diabetes). The medication was not available according to the signed MARThis deficient practice could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and a decline in health.Findings include:Record review of Resident #1's face sheet dated 09/30/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of type 2 diabetes (chronic medical condition in which the body does not produce enough insulin or does not use insulin effectively), morbid obesity, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #1's most recent quarterly MDS assessment, dated 6/11/25 revealed the resident had a BIMS score of 10 indicating moderate cognitive impairment for daily decision-making skills.Record review of Resident #1's care plan dated 08/08/25 indicated Resident #1 used diabetic medications. Interventions included to provide and document teaching to resident/family/caregiver and address identified roadblocks to compliance Record review of Resident #1's physician orders included the following medications: Glimepiride oral tablet I mg-Give I tablet by mouth one time a day for diabetes mellitus-ordered 12/11/2024 Basaglar Kwik Pen subcutaneous solution Pen-injection 100 unit/ml-Inject 20 unit subcutaneously one time a day relate to type 2 diabetes mellitus-ordered 02/14/25Becton [NAME] duo miscellaneous 30 g X mm. Inject 1 application subcutaneously before meals and at bedtime for diabetes mellitus-ordered 04/14/25. Record review of Resident #1's Medication Administration Record for July 2025 revealed the scheduled medication of glimepiride I mg was not administered on July 27, 28, 29, 30 and 31, 2025. The medication was to be administered I tablet by mouth one time a day. Further review of the MAR revealed MA A documented an UN in the section meant for administered medication indicating unavailable medication for July 28 and 29, 2025. Review also revealed MA C documented UN indicating unavailable for July 27, 30, 31 2025. During an interview on 09/30/2025 at 9:45a.m, RP P stated she was the responsible party for Resident #1. RP P stated on 07/26/25, she had a 90-day supply of glimepiride for diabetes delivered to the facility. The staff lost the medication. The facility informed her that they would have the doctor renew the medication which they did not do as promised. On 07/31/25, the facility still had no medication for the resident. The RP explained she complained to the facility corporate office, and DON assured her the facility will provide the medication and pay for it. She was assured by DON and staff that they had the medication in stock and had been administering the medication to Resident #1. The RP P stated, the resident may have missed his medication for more than four days. The RP P explained the glimepiride was a Page 1 of 3 675145 675145 11/20/2025 Buena Vida Nursing and Rehab Odessa 3800 Englewood LN Odessa, TX 79762

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some significant medication used for control of his diabetes mellitus. She stated not taking this medicine will complicate [KS5] the control of his blood sugar resulting in serious harm to his health. In an interview with MA B on 09/30/25 at 1:30p.m, she stated she was the medication aide working on hall 200 where Resident #1 was residing. She said she did not give Resident #1 his glimepiride medication on July 28 and 29, 2025 as ordered. This was because the medication was not available. MA A explained that the family supplies the medication for the resident. She notified the charge nurse that the medication was not available to let the family know. MA A said she could not remember the charge nurse she informed. MA A added that it was a common practice to retrieve the medication from the E-kit (emergency kit) but did not remember if the charge nurse attempted to check the E-kit. She stated the medication was used to treat high blood sugar for diabetic residents. She noted Resident #1 could get diabetic complications [KS7] for not receiving the medication as ordered. During interview with MA C on 09/30/25 at 10:11a.m, she stated she has been working for the facility for 5 years and was responsible for giving medication to Resident #1. MA C confirmed she signed on Resident #1's MAR on July 27, 30 and 31, 2025 that the diabetic medication of glimepiride was not available. She stated one of days the medication was not available the resident's was in the room. The MA C informed wife the resident was out of the medication. MA C said the wife told her she had already filled the medication. MA C stated Resident #1's wife came back the next day and informed her the medication was already delivered and somebody from the facility signed for it. The continued and stated there was no longer a refill left because the order was already filled. MA C said she informed the nurse on duty of resident's information regarding the delivered medication. The medication aide stated she could not remember the charge nurse she informed since it has been more than a month. MA C stated she did not know why it took days before Resident #1 started receiving his medication. She explained, it was normal protocol to retrieve the medication from the E-kit. She did not know if the charge nurse [KS10] ied to get the medication from the E-kit. During an interview with DON on 09/30/25 at 10:43a.m, she stated she was not aware Resident #1 missed his medication of glimepiride for 5 days until the surveyor brought it to her attention. The DON said she communicated with the corporate office about the medication issue. She stated a staff member signed for the medication, but they could not locate the medication. She notified the physician and got the medication refilled. Meanwhile, she was not aware Resident #1 missed so many days. The DON stated it was lack of communication between the staff and herself. She stated, looking at the MAR, it appears Resident #1 did not receive medication of glimepiride for 5 days from July 27 through 31, 2025. In an interview with PH D on 10/01/25 at 10:38a.m, he stated he was familiar and responsible for Resident #1. He said he was made aware that Resident #1 missed some of his medication of glimepiride. PH D stated he was told to reorder the medication because the facility could not find it after it was delivered.Record review of the facility document titled Medication Administration and general guidelines undated reflected the following below. The policy did address the facility E-kit policy.Policy:Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in Link Rx otherwise authorized personnel should refer to Drug Reference material provided by facility.Procedure:1) Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications.2) Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated 675145 Page 2 of 3 675145 11/20/2025 Buena Vida Nursing and Rehab Odessa 3800 Englewood LN Odessa, TX 79762

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to the resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication. The interaction with the physician is documented in the nursing notes and elsewhere in the medical record as appropriate.3) The person administering medications adheres to Universal Precautions, using proper hand hygiene, gloves when appropriate, before beginning a medication pass, prior to handling any medication, and after coming into direct contact with a resident. Gloves will be worn before administration of any ophthalmic, optic, intranasal, inhaled, topical, vaginal, or rectal medication.4) Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with policy and procedure for self-administration of medications.5) Medications are administered at the time they are prepared. Medications are not pre-poured. 6) All current medications and dosage schedules, except topicals used for treatments, are listed on the resident's medication administration record (MAR). 675145 Page 3 of 3