Health inspection·November 21, 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 observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one (Resident #1) of six residents reviewed for pharmaceutical services.The facility failed to ensure an unknown staff did not leave Resident #1's medications inside the resident's room for the resident to take unsupervised which resulted in her dropping one Colace pill and one Amlodipine pill on an unknown date.This failure could place the residents at risk of not receiving medications as ordered by the physician for 1 of 6 residents (Resident #1) reviewed for pharmaceutical services.Findings included: Record review of the face sheet dated 10/25/2025 indicated that Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including congestive heart failure, which is when the heart cannot pump blood throughout the body efficiently, generalized edema, which is swelling caused by fluid build-up, myocardial infarction, which is a blockage in the heart, chronic obstructive pulmonary disease, which is when airflow gets trapped in your lungs making it feel difficult to breath, constipation which is when you cannot have regular bowel movements, essential hypertension which is high blood pressure with no clear cause. Record review of the MDS dated [DATE] indicated that Resident #1 had a BIMS score of 15. Her score indicated that she had normal cognition, and no major memory or cognition issues. Record review of Resident #1's Medication Review, dated 10/16/25, revealed an order for amlodipine 10mg, give 1 tab by mouth one time a day in the morning and Colace 100mg by mouth every 12 hours. Record review of the MARs dated 10/16/2025 revealed that Resident #1 was prescribed amlodipine 10mg, one tablet in the morning by mouth and Colace 100mg one capsule every 12 hours by mouth as part of her daily medication regimen. Record review of the facility police entitled Medication Storage and dated 1/20/2021 which indicated that It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms).During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. During an observation on 10/15/25 at 4:33 p.m. Resident #1's previous bedroom (room [ROOM NUMBER]) revealed two pills on the ground; one orange and one white, which were identified by the DON as Colace, a stool softener, and amlodipine which is a blood pressure medication. During an interview on 10/15/2025 at 12:50 p.m. Resident #1 stated that she found little white pills on the floor in her previous room which was room [ROOM NUMBER] and that the med aides or nurses did not wait for her to take her medication and she thought she dropped some of her pills. Resident #1 stated that the staff got in a hurry and that she didn't have time to ask them what she was taking. During an interview (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: 675976 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 675976 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835 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)