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 did not provide pharmaceutical services to meet the
needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that:
The facility failed to ensure Resident #1 received his inhaler treatment within one hour before and one hour
after the time the treatment was ordered to be given.
This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the
medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and
hospitalization.
Findings included:
Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the
facility on [DATE] with chronic obstructive pulmonary disease (a type of progressive lung disease
characterized by long-term respiratory symptoms and airflow limitation), acute and chronic respiratory
failure, anxiety disorder, dependence on supplemental oxygen, and essential hypertension (high blood
pressure).
Review of Resident #1's quarterly MDS assessment, dated 05/10/23, reflected a BIMS of 15, indicating no
cognitive impairment. Section J (Health Conditions) reflected he had shortness of breath with exertion,
when sitting at rest, and when lying flat. Section O (Special Treatments, Procedures, and Programs)
reflected he was receiving oxygen therapy.
Review of Resident #1's quarterly care plan, dated 05/12/23, reflected he had difficulty breathing related to
COPD with an intervention of following physician orders.
Review of Resident #1's physician order, dated 06/02/17, reflected Breo Ellipta Aerosol Powder Breath
Activated 100-25 MCG/INH - one inhalation - inhale orally one time a day (scheduled at 8:00 AM) related to
COPD with (acute) exacerbation.
An observation and interview on 07/31/23 at 9:46 AM, revealed Resident #1 in bed receiving continuous
oxygen from his concentrator. He stated he was waiting on his inhaler which he was supposed to receive at
8:00 AM. He had to stop a couple of times during the interview to take a few breaths, stating he was feeling
short-of-breath. He stated he did not usually have to wait that long to receive his inhaler treatment or
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:
675857
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
675857
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/31/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
William R Courtney Texas State Veterans Home
1424 Martin Luther King Jr LN
Temple, TX 76504
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
During an interview on 07/31/23 at 9:53 AM, RN A stated Resident #1 had not yet received his inhaler
treatment. She stated they were running a little behind because they had to send another resident to the
ER earlier in the morning and it was a busy morning. She stated she would notify the medication aide that
Resident #1 was requesting his inhaler.
Residents Affected - Few
Observation on 07/31/23 at 10:08 AM revealed Resident #1 receiving his inhaler treatment.
During an interview on 07/31/23 at 12:23 PM, the DON stated her expectation was that medication was
administered to the residents within an hour before or an hour after the ordered scheduled time. She stated
it was not acceptable for Resident #1 to go two hours without receiving his inhaler. She stated it was the
responsibility of the charge nurses to ensure medications were administered timely. She stated a negative
outcome could be respiratory distress.
Review of the facility's undated Medication Administration policy reflected the following:
Objective: Resident medications are administered in an accurate, safe, timely, and sanitary manner.
.
Physician's Orders - Medications are administered in accordance with written orders of the attending
physician.
.
6. Administer medications within 60 minutes of the scheduled time or time range.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675857
If continuation sheet
Page 2 of 2
