F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used
in the facility were labeled and stored in accordance with professional standards for 1 of 8 residents
(Resident #1) reviewed for pharmacy services.
The facility failed to ensure MA A secured Resident 1's medication when she left Resident #1's medications
on her bedside table for her to self-administer and did not ensure the resident took her medication.
This failure could place residents at risk of not receiving drugs and biologicals as needed, medication
errors, medication misuse, and drug diversion.
Findings included:
Record review of Resident #1's face sheet reflected she was a [AGE] year-old female, admitted to the
facility on [DATE]. Her diagnoses included cerebral infarction (Stroke a disruption of the blood flow to the
brain causing part of the brain to die), dehydration, post-traumatic stress syndrome, unspecified psychosis,
and anxiety disorder.
Record review of Resident #1's care plan dated 10/17/2023 reflected she was resistive to care related to
episodes of refusing medication. Her goal was for her to cooperate with taking medications as per medical
doctors orders through next review date. Interventions were If Resident #1 resist taking medications leave
and return 5-10 minutes later and try again. If Resident #1 continues to refuse to take medications notify
medical doctor and responsible party and document in chart.
Record review of Resident #1's Quarterly MDS assessment, dated 10/24/2024, reflected she had a BIMS
score of 15, which indicated she was cognitively intact. Resident #1 was coded Substantial Maximal
Assistance with her ADLs (dressing, bathing, grooming, and toileting) indicating the helper or staff
performed more than half the effort for the resident to complete the task .
In an interview and observation on 11/20/24 at 10:30 AM Resident #1 stated she had no concerns with
abuse or neglect and felt safe there. She stated she had a call light and staff get to her as soon as they
could. She stated she received her medication as scheduled. Observed 2 clear oblong pills laying on the
bedside table, Resident #1 stated they were fish oil pills. Resident #1 stated staff leave her medication,
peanut butter crackers, and water on the bedside table and do not watch her take her medications. She
stated MA A administered her morning medications.
(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:
675431
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
675431
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Red Oak Health and Rehabilitation Center
101 Reese Dr
Red Oak, TX 75154
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In an interview on 11/20/24 at 10:40 AM MA A stated she has worked at the facility for 2 years. She stated
she was delegated to pass medication. She stated when passing medication she matched the name to the
medication, matched the medication dosage, and read the directions on the medication. She provided the
medication with water, watched the resident take the medication, and checked off the medication on the
MAR. She stated if the resident refused, she must notify the nurse. She stated she administered Resident
#1's medication this morning and watched her take her medication. She stated she administered the
medication to Resident #1 and walked back to the medication cart to document it in the MAR. As she was
documenting she was overseeing the resident, she thought the resident had taken all her medications, so
she moved on to the next resident . MA A stated she was responsible for making sure residents swallowed
and took their medications. She stated leaving medications at the bedside may result in the resident not
taking her medications.
In an interview on 11/20/24 at 11:47AM the ADM stated staff were not supposed to leave any medications
in the room. He stated the staff were supposed to stay with the resident and make sure the medications
were swallowed. The ADM stated staff were educated on the medication administration process by the
DON, the ADON, and the unit mangers. The ADM stated the risk for leaving medications on the resident's
bedside table and not ensuring residents were taking medications could result in subtherapeutic effects of
medications, missed medications, or a demented resident could wonder in the room and take the
medications that were not theirs.
In an interview on 11/20/24 at 12:09 PM the DON stated MA A never should leave medications on beside
tables. She stated she has recently educated all nurses and medication aides on medication pass step by
step instructions. She stated she was responsible for educating the staff on the medication pass policy. The
DON stated all staff were responsible for passing medications and were checked off visually on skills
annually by the DON. She stated negative effects included the resident may not take their medications.
Record review of facility Inservice titled Medication Pass Process dated 11/01/2024 reflected staff were
never to leave the medications in the room for the resident to take later. The in-service was signed by MA A.
Record review of facility policy titled Administering Medications dated 2001 and Revised December 2012
reflected, Medications shall be administered in a safe and timely manner, and as prescribed. Residents
may self-administer their own medications only if the Attending Physician, in conjunction with the
Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so
safely.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675431
If continuation sheet
Page 2 of 2
