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
observation, 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 for 1 of 3 residents (Resident #1) reviewed for pharmaceutical services.LVN C failed
to remain in the room and monitor Resident #1's Family Member A administer medications to Resident #1.
This failure could place residents at risk of not receiving the therapy needed. Findings included:Record
review of Resident #1's admission MDS Assessment, dated 11 /14/25, reflected the resident was a [AGE]
year-old male, who admitted to the facility on [DATE]. The resident's diagnoses included spinal stenosis,
lumbar region without neurogenic claudication (degenerative condition characterized by the narrowing of
the spinal canal in the lower back), hypertension (high blood pressure), diabetes mellitus (disease that
occurs when blood sugar are too high), and anxiety disorder (feeling of fear, and uneasiness). Resident
#1's BIMS score was not completed. Record review of Resident #1's Care Plan, dated 11/14/25, did not
address medication administration. Observation on 11/18/25 at 9:22 AM, LVN C entered Resident #1's
room, LVN C had a clear cup with pills inside. Resident #1's family member took the cup with pills and
began to give Resident #1 pills 1 by 1. LVN C was observed checking Resident #1's blood pressure then
blood sugars, once done checking LVN C was observed leaving the room before ensuring Resident #1 took
all his medications. Resident #1's family member was observed still administering two pills after LVN C left
the room. LVN C was observed to return to her med cart that was located at end of the hall by the nurse's
station. Interview on 11/18/25 at 9:27 AM, Resident #1 was observed sitting in his chair. Resident #1 stated
he was doing well, Resident #1's Family Member A stated she had just finished giving resident last 2 pills.
Resident #1's Family Member A stated Resident #1 does better and will take all his medications when she
gives them to the resident. Resident #1's Family Member A stated she ensures he takes them all. Interview
on 11/18/25 at 10:46 AM, LVN C revealed she was the nurse assigned to Resident #1. She stated she
provided Resident #1's morning medication. LVN C stated Resident #1's family member gives the pills to
Resident #1 because he swallows them better when family member gives them to him. LVN C stated she
left the room and returned to the room to ensure that all his medications were taken. She stated she had
good communication with Resident #1's Family Member and the Family Member ensured her Resident #1
took all his medications. LVN C stated it was the metformin pill that was still in the cup when she left the
room. She stated she should had stayed in the room to ensure all medications was taken. She stated the
potential risk of not staying in the room to ensure all medications was given would be someone else taking
the medications. Interview on 11/18/25 at 3:47 PM, Unit Manager D revealed nurses should follow the five
rights of medication administration which were right patient, right drug, right dose, right route, and right
time. She stated nurses should stay with the residents until all medications had been administered. She
stated she was made aware of the situation
(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:
675834
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
675834
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookdale Galleria
2929 Post Oak Blvd
Houston, TX 77056
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
with LVN C leaving the room. She stated it was a failure if the nurse left without ensuring all medications
was administered. Unit Manager D stated the potential risk would be resident choking.Interview on
11/18/25 at 4:45 PM, the DON revealed all nurses should follow the five rights of medication administration.
She stated all nurses should stay in the room to ensure all medications had been administered. She stated
LVN C failed to ensure that the resident swallowed all his medications before leaving the room. The DON
stated the potential risk would be anything could happen to the medication if left unattended. Record review
of the facility's Medication Administration policy, revised May 2025, reflected the following: A. FOR ORAL
MEDICATION ADMINISTRATION: . 7. Observe the client taking the medication.
Event ID:
Facility ID:
675834
If continuation sheet
Page 2 of 2