Health inspection·November 5, 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 interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, and a system of medication records that enabled periodic accurate reconciliation and accounting of all controlled medications to meet the needs of 1 of 3 residents (Residents #1) reviewed for pharmacy services. -LVN V and RN E, who signed out control pain medication from the control book, did not sign off on the TAR or MAR that control medications were administered for Resident #1. This failure could place residents at risk of not receiving their medication and drug diversion. Record review of Resident #1's face sheet dated 11/05/25 revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included displacement fracture of base of neck of right femur, subsequent encounter for closed fracture without routine healing (received active treatment for a fracture and was in recovery phase) intracapsular fracture of right femur (a break in the upper part of the right thigh bone that happens inside the hip joint), and dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities).Record review of Resident #1's care plan, dated 09/29/25, read, .the resident is on pain medication therapy (oxycodone) related to acute pain.Record review of Resident #1's October 2025 order summary report read, Oxycodone HCI Oral Tablet 5 MG (Oxycodone HCI) give 1 tablet by mouth every 6 hours as needed for Pain - Severe, order dated 09/26/25, and Oxycodone HCI Oral Tablet 5 MG give 1 tablet by mouth one time a day for pain, order dated 10/05/25.Record review of Resident #1's controlled drug receipt/record/disposition form, dated 09/27/25, revealed one oxycodone IR tablet, 5 mg, was signed out on 10/08/25 at 11:23 p.m.Record review of Resident #1's controlled drug receipt/record/disposition form, dated 09/27/25, revealed one oxycodone IR tablet, 5 mg, was signed out on 10/09/25 at 8:00 a.m.Record review of Resident #1's controlled drug receipt/record/disposition form, dated 10/07/25, revealed one oxycodone IR tablet, 5 mg, was signed out at 8 a.m. on 10/09/25.Record review of Resident #1's October 2025 TAR for Oxycodone HCl Oral Tablet 5 mg did not reveal the medication was signed as administered on 10/08/25 for 11:30 p.m., and for 10/09/25 for 8:00 a.m During an observation of the control sheet and interview on 10/29/25 at 4:42 p.m., the DON said LVN V signed out Oxycodone HCl oral tablet 5mg from the PRN count sheet at 11:30 p.m. on 11/08/25. The DON said LVN V did not sign off on the TAR for 11/08/25 at 11:30 p.m., which could indicate LVN V did not administer the control PRN pain medication to Resident #1. The DON said MA L signed out the control pain medication from the scheduled MA control count sheet for 8:00 a.m. on 10/09/25, and she documented 15 on the MAR, which meant MA L did not administer the medication to Resident #1. The DON also said RN E signed out the same controlled pain medication from the PRN control sheet for Nurses on 10/09/25 for 8:00 a.m., but RN E did not sign off on the TAR. The DON said that if the medication were not signed off on the TAR or the MAR, it would mean the resident did not receive the medication and that it was a Page 1 of 3 675323 675323 11/05/2025 Baywind Village Skilled Nursing & Rehab 411 Alabama Ave League City, TX 77573

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication error. During an interview on 11/29/25 at 5:01 p.m., the DON asked the ADON if she destroyed oxycodone for Resident #1. The ADON said she did not remember destroying any controlled pain medication for Resident #1 in September 2025 or October 2025.During an interview on 11/29/25 at 5:03 p.m., the DON stated that an agency nurse (LVN V) signed off the evening PRN control pain medication in the control book on 11/08/25 at 11:30 p.m., but did not sign on the TAR. The DON said it could imply the pain medication was not administered to Resident #1 on 11/08/25 at 11:35 p.m. because it was not signed on the TAR as administered. The DON said two nurses, or the aide, should have destroyed the medication, documented on the count sheet that the medication was destroyed, and signed off on the control count sheet. The DON said medication should be signed off on the control count sheet, and after the nurse or MA administered the medication, the nurse or MA should sign off on the MAR or TAR. The DON said it was a medication error because LVN V and RN E signed off the control pain medication on the count sheet, and LVN V and RN E did not sign on the MAR or TAR.During an interview on 11/05/25 at 8:49 a.m., the ADON said when LVN V and RN E signed off on control medication from the narcotic book, they should also sign off on the MAR or TAR after administering the medicine to Resident #1. She said that if LVN V and RN E did not sign off on the MAR or TAR after administration of the control pain medication, it meant the medication was not administered. She said Resident #1 could still be in pain. The ADON said two nurses or medication aides have to destroy any controlled medication, and both staff would sign off on the control book that the medication was destroyed.During a telephone interview on 11/05/25 at 10:01 a.m., MA L said scheduled control pain medications were kept in the medication aide cart, while the nurse kept the PRN control pain medication in the nurse's cart. MA L said RN E walked up to her in the medication room on 10/09/25 and said she was going to give Resident #1's control PRN pain medication. MA L told RN E she was going to administer Resident #1 his scheduled 8:00 a.m., scheduled control pain medication, and she had pouched out the medication. MA L said RN E told her to give her the medication, and she would administer the pain medicine to Resident #1, and she handed Resident #1's pain medication to RN E. She said that when medication was signed out on the control sheet, it should correspond with the MAR, and if it did not, it would indicate a medication error. MA L said she did not sign the MAR because the nurse gave the medication, and she did not know if RN E had already punched out the nurse's PRN medication. She said the nurse should have wasted one of the medications because she had two tablets of pain medication at the same time. MA L said when narcotics were wasted, two nurses should dispose of the medication, and both staff would sign off on the control sheet.During an interview on 11/05/25 at 10:38 a.m., RN E said she had already punched out the control PRN pain medication for Resident #1 before she told MA L she was going to give Resident #1 his PRN controlled pain medication. RN E said MA L gave her the scheduled 8:00 a.m. pain control medication for Resident #1 because both of them were about to administer the same pain medication at the same time. She said she wasted her PRN pain control medication in the pill bottle (drug buster), and she forgot to have a witness sign when she wasted the pain control medication or signed in the control book that the medication was wasted. RN E said anybody with untrained eyes would think she took the medication because she signed off the medication from the control book and did not sign on the MAR or TAR that she administered the pain medicine, and it looked like a drug deviation.During an attempted telephone interview on 11/05/25 at 11:04 a.m., the LVN V (agency nurse), who worked on 10/08/25 and signed off medication on the control book, but it was not signed off on the TAR, did not answer and the surveyor left a message. LVN V did not return the call.Record review of the facility policy and procedure, undated, titled Narcotic Count Before and After Shift, read in part, . Purpose: to ensure the accurate accountability, security, and proper handling of 675323 Page 2 of 3 675323 11/05/2025 Baywind Village Skilled Nursing & Rehab 411 Alabama Ave League City, TX 77573

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few all controlled substances in the facility. This policy safeguards residents, staff, and the facility from medication errors, discrepancies, and potential diversion. procedure #5. Wasting narcotics. Wastage of any portion of a controlled substance must be: Witnessed by two licensed nurses. Documented on the Controlled Substance Record (including amount wasted, reason, date/time, and both nurses' signatures) .Record review of the facility policy on medication administration dated 2001 MED-PASS, Inc, revised April 2019, read in part, Medications are administered in a safe and timely manner, and as prescribed. policy interpretation and implementation #22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 675323 Page 3 of 3