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 Page 1 of 2 675976 675976 11/21/2025 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 10/15/25 at 4:40 p.m. LVN C stated that the pills could have gotten on the floor from the resident spitting them out when the staff was not looking, or the staff dropped the pills and did not pick them up. She stated that the pills should not have been on the floor and that there was a risk of another resident finding the medication. LVN C said taking it could cause adverse health effects and there was a risk of the resident whose medication it was missing a dose, as it could have also caused them adverse health effects. During an interview on 10/15/25 at 4:43 p.m. MA A stated that the pills could have gotten on the floor from the resident spitting them out when the staff is not looking. She stated that the staff could have dropped the pills and did not pick them up. She stated that the pills should not have been on the floor and that there was a risk of another resident finding the medication. MA A stated taking the medication if it was not prescribed to you could have caused adverse health effects and there was a risk associated with missing a dose of the medication if it was prescribed to you, as it might have caused adverse health effects. During an interview on 10/15/25 at 4:50 p.m. the DON stated that the pills could have gotten on the floor from the resident spitting them out when the staff is not looking, or the staff could have dropped the pills and not picked them up. She stated that the pills should not be on the floor and that there is a risk of another resident finding the medication. The DON said taking the medication if it was not prescribed to you for your specific medical condition it could have caused adverse health effects. She stated that there is a risk of the resident whose medication it was missing a dose, as it can also cause them adverse health effects. During an interview on 10/16/25 at 12:08 p.m. MA B stated that the pills could have gotten on the floor from the resident spitting them out when the staff was not looking, or the staff could have dropped the pills and did not pick them up. She stated that the pills should not be on the floor and that there was a risk of another resident finding the medication as taking medication that does not belong to you could have caused adverse health effects. MA B stated that taking medication that does not belong to you could have caused adverse health effects. She stated that there is a risk of the resident whose medication it was when they missed a dose, as it could have also caused them adverse health effects. During an interview on 10/16/25 at 1:30 p.m. the ADM stated that the policy for medications is to always be kept safe and always secured. The administrator stated that they moved Resident #1 from room [ROOM NUMBER] to room [ROOM NUMBER] last week. The ADM stated that the risk of leaving medications in the room is the resident not taking the medication or another resident taking a medication that they do not need. She stated that the resident could have dropped the pills and the staff member was not there to see it but that the medication, if administered properly should not be on the floor. During an interview on 10/16/25 at 2:10 p.m. the ADON stated that the pills could have gotten on the floor from the resident spitting them out when the staff is not looking, or by the staff dropping the pills and not picking them up. She stated that the pills should not have been on the floor and that there was a risk of another resident finding the medication. The ADON stated taking medication that is not prescribed to you could have caused adverse health effects. She stated that there was a risk of the resident whose medication it was in missing a dose, as it also could have caused them adverse health effects. During an interview on 10/16/25 at 2:17 p.m. CNA D stated that the pills could have gotten on the floor from the resident spitting them out when the staff was not looking, or the staff dropped the pills and did not pick them up. She stated that the pills should not have been on the floor and that there is a risk of another resident finding the medication and taking it. CNA D stated that taking medication that is not prescribed to you could cause adverse health effects and there was also a risk of the resident whose medication it was when they missed a dose, as it also could have caused them adverse health effects. 675976 Page 2 of 2