Health inspection·November 25, 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. Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments under proper temperature controls and permitted only by authorized personnel to have access to the keys for 1 of 3 nurse medication storage carts (A Hall) reviewed for storage of medication and biologicals.The facility failed to ensure 15 tablets of APAP/Codeine 300-30mg (medication used for moderate to severe pain) was not, the medication expired on 11/01/25, and had been expired for 10 days, and were not removed from use.This failure could place residents at risk of adverse reactions to medications, misappropriation of medications, and not receiving therapeutic effects of medication.Findings include:Observation of the facility A Hall medication storage cart and interview with RN A on 11/10/25 at 06:45 p.m. revealed in second draw of the cart was an affixed lock box which revealed the following:-an individual medication card with 15 untouched tablets of APAP/Codeine 300-30mg with an expiration date of 11/01/25 and fill date of 11/01/24, the medication had been expired for 10 days and had not been removed from use in the medication cart. RN A stated the APAP/Codeine 300-30mg medication had been expired since 11/01/25 and she said 15 out of 30 tablets were left. RN A said she started working with the facility about 8 months ago. RN A said she was responsible for administering medication out of the A-hall nurse medication cart but had not given any of the expired APAP/Codeine 300-30mg. RN A said she was trained by the facility on medication storage, making sure medications were not expired before giving the medication and keeping the cart stocked, free of expired medications and spills. RN A said if residents were administered expired medications it could lead to medication poisoning or sickness. RN A said she would remove the expired medications from the cart.During an interview on 11/11/25 at 1:10 p.m., the DON said there should be no expired medications inside the medication room or inside the medication carts. The DON said the Nurse working on the medication cart checked the medication cart every time they work on the medication cart. The DON said nurses were to check for expired medications and discharged residents' medication to be removed for disposal during each shift. The DON said she was responsible in ensuring the nurses were checking the medication carts for removal and disposal of expired medications and she said she was not sure how it got overlooked. The DON said if the medication was not given for months, then they could expire and be overlooked on the medication cart. She said the effects of expired medications could range from reduced effectiveness to unfavorable side effects.Record review of the facility's individual control drug record for the APAP/Codeine 300-30mg indicated it was last given 10/26/2025 at 6:47 a.m. with an ending count of 15 tablets.Record review of the facility's pharmacy monthly medication review for storage, dated 7/2025 to 10/2025, reflected no evidence of expired medications on the medication carts needing removal. Record review of the facility's policy, dated 11/2020, titled Storage of Medications reflected in part: .Policy: The facility stores all drugs and biologicals in a safe secure and orderly manner.3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean safe and Page 1 of 2 675563 675563 11/25/2025 Colonial Nursing & Rehabilitation Center 508 Pierce St Lindale, TX 75771

F 0755 Level of Harm - Minimal harm or potential for actual harm sanitary manner.4. Drug containers that have missing incomplete improper or incorrect labels are returned to the pharmacy for proper labeling before storing discontinued outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Residents Affected - Few 675563 Page 2 of 2