Inspection·November 20, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 record review and interview, the facility failed to provide pharmaceutical services, including the accurate administering of drugs for 1 of 5 Residents (Resident #1) reviewed for pharmacy services. 1) The facility failed to ensure Licensed Vocational Nurse (LVN) A did not administer PRN Ativan (Anti-Anxiety/Sedative medication), after it was ordered to be discontinued. The facility failed to remove anti-anxiety (Ativan) medication from the medication cart after it was ordered to be discontinued by the physician for Resident #1 The noncompliance was identified as past noncompliance. The noncompliance began [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigation began. These failures could place residents who received medications at risk of receiving unnecessary doses of medication, experiencing undesirable side effects as well as potentially causing a physical or psychological decline in health. Findings include: Review of Resident #1's face sheet, care plan, MDS and Physician's orders revealed resident is a 75 -year-old female who was admitted on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Chronic Kidney Disease, Sjogren syndrome, Essential (Primary) Hypertension, and has a BIMS score of 11. Record review of Resident #1's orders showed an active order of for Tramadol HCl Oral Tablet 100 MG, give every six hours as needed for pain. Record review of Resident #1's orders showed a discontinued order for Lorazepam (Ativan) oral tablet 1 Mg, give every four hours as needed for anxiety and restlessness for 14 days discontinued on [DATE]. Record review of Resident #1's medication narcotic sheet dated [DATE]: 06:27 AM showed Ativan 2mg by mouth (PO) was administered versus the ordered Tramadol 100mg PO given by LVN A. Record review of nursing notes for Resident #1 revealed on [DATE]: 5:16 PM - Resident was transferred to a hospital on [DATE] 5:25 PM. Note states hospitalization was related to resident covid (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 3 Event ID: 675982 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 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 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)