Health inspection·August 18, 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 assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determines that drug records are accurate to meet the needs of each resident, for 1 of 2 residents (Resident #1) reviewed for medication administration.The facility failed to ensure Resident #1 had an order for Acetaminophen/Tylenol 650 mg every 4 hours as needed for pain/fever in the Electronic Medication Administration Record per the facility's standing orders. The facility failed to ensure LVN A documented the administration of Acetaminophen/Tylenol 650 mg every 4 hours as needed for Resident #1 on 07/17/2025. These failures could place residents at an increased risk for inaccurate drug administration and not receiving the care and services to meet their individual needs.Findings included:Record review of a face sheet dated 08/18/2025 indicated Resident #1 was a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included sepsis (life threatening complication related to infection), diabetes mellitus (too much sugar in the blood), dependence of renal dialysis (life sustaining treatment for kidney failure) and hypertension (high blood pressure).Record review of the Discharge MDS assessment dated [DATE], indicated Resident #1 was able to make was able to make herself understood and understood others. The MDS assessment indicated Resident #1 had a BIMS summary score of 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #1 rarely had any pain that interfered with sleep, therapy or ADLs. Record review of Resident #1's Order Summary Report dated 08/18/2025 indicated she had an order for Acetaminophen/Tylenol 325 mg, two tablets by mouth every 4 hours as needed for pain started on 07/20/2025 and discontinued on 07/25/2025.Record review of Resident #1's care plan did not address pain.Record review of Resident #1's electronic medication administration record dated 07/17/2025 - 07/18/2025 did not indicate Acetaminophen/Tylenol had been administered.Record review of Incident Case Report dated 08/13/2025 documented by the DON, indicated Resident #1 alleged she had received her roommate's medication the evening of 07/17/2025. The report indicated, as LVN A walked into Resident #1's room, LVN A said to Resident #1's roommate that her Seroquel had been delivered as she walked through the room to administer Resident #1's medication. The report indicated that LVN A stated Resident #1's roommate mistook the information and thought LVN A had gave Resident #1 the (recently delivered from the pharmacy) Seroquel (medication used mental and mood conditions). The report indicated that Resident #1 and the roommate continued to insist LVN A had given the Seroquel to Resident #1. The report indicated LVN A told Resident #1 she would monitor her throughout the night for peace of mind and assured Resident #1 if she had given her the wrong medication .it would not cause her harm and would possibly make her sleepy. The report indicated, the DON had completed an assessment the next morning on 07/18/2025 and noted Resident #1 was somnolent but easily rousable and coherent. The report indicated, Resident #1 stated she felt sleepy, but not bad.During Page 1 of 2 675561 675561 08/18/2025 Heritage Plaza Nursing Center 600 W 52nd St Texarkana, TX 75501

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few an interview on 08/18/2025 at 12:05 AM, CNA B stated on 07/18/2025 Resident #1 was hard to arouse, and she was unable to get her dressed. CNA B stated she was concerned because Resident #1 was always chipper and ready to get dressed in the mornings. CNA B stated after several attempts to wake up Resident #1 to no avail, she notified the DON.During an interview on 08/18/2025 at 12:31 PM, LVN A said she had given Acetaminophen/Tylenol to Resident #1 for pain around 10:30 PM on 07/17/2025. LVN A said she had a standing order for the prn medication and had not contacted the doctor. LVN A said someone had told her that Resident #1 was in pain and was waiting on the prn medication to be administered. LVN A said she could not recall why she did not document her assessment of Resident #1's pain on the required pain scale rating in the electronic medication administration record. LVN A said she guessed she was busy and forgot. LVN A said she it was important to document and complete pain assessments before and after giving pain medications to measure the need and effectiveness. LVN A said it was important to document the medication, dosage and time to prevent over medicating a resident which could result in toxicity. LVN A stated she was not aware that Resident #1 or the roommate thought she had given the roommate's Seroquel to Resident #1 on 7/17/2025. LVN A stated she first become aware on 07/18/2025 when the DON had contacted her by telephone. LVN A stated she did not tell Resident #1 she would monitor her throughout the night. During an interview on 0n 08/18/2025 at 02:02 PM, the Director of Rehabilitation stated Resident #1 was not acting her normal self. The Director of Rehabilitation stated Resident #1 was drowsy and unable to hold a conversation. The Director of Rehabilitation stated she notified the DON of the change and stated she did not take Resident #1 for therapy that AM. The Director of Rehabilitation stated the DON came to Resident #1's room and was able to arouse her and continued to get Resident #1 dressed. During an interview on 08/10/2025 at 01:10 PM, the DON said she was not aware LVN A had not completed the required pain assessment documentation on Resident #1 until today. The DON said when a prn medication was administered, the medication was entered on the electronic medication administration record. Then, the assessment record for pain would open for further documentation by the administering nurse to complete. The DON said it was important for coordination of care between staff and to monitor the proper effectiveness or lack of effectiveness that the Resident had experienced after taking the medication. The DON said if the medications were not documented after being administered, the resident was at risk of having too much or too little which could result in harm. The DON said she expected the staff to follow the protocol for medication administration. Record review of the facility's policy titled, Medication Administration General Guidelines, Pharmacy Policy & Procedure Manual Section 7.1 dated 01/24, indicated, .2. Facility staff administering medication shall comply with the following.1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. 675561 Page 2 of 2