Health inspection·April 3, 2025

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 interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1of 5 residents (CR#1). The facility failed to ensure that CR#1's Lorazepam was ordered, received, and dispensed when CR#1 was admitted to the facility. This failure could place the residents at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life and hospitalization. Findings included: Record review of CR#1's admission face sheet, revealed he was a [AGE] year-old who was admitted on [DATE] and discharged on 03/14/2025. His diagnoses included hyperlipidemia (high level of fat in the blood), aggressive behavior (type of behavior intending to cause physical or mental harm), hypothyroidism (thyroid not producing adequate thyroid hormone), anxiety (mental health condition characterized by excessive worry and fear), Parkinson (disorder of the central nervous system that affects movement), psychosis (mental disorder characterized by a disconnection from reality) and schizoaffective (mood disorder). Record review of CR#1's admission MDS dated [DATE] revealed the resident BIMS score was 07 indicating the resident was severely impaired, he was set up only for eating, needed substantial/maximal assistance with shower/bathe self, and upper body dressing. He was partial/moderate assist with oral hygiene, toileting, lower body dress, and personal hygiene. For Behavior he was coded had having physical, verbal, or other behavioral symptoms every 1-3 days and reject care every 1-3 days. For bowel and bladder, he was occasionally incontinent of bladder and always incontinent of bowel. Record review of CR#1's physician's orders dated 03/12/2025 revealed an order for Lorazepam Oral Tablet 0.5 mg by mouth two times a day at 8:00am and 8:00pm for mental health. Record review of CR#1's medication administration record for March 2025 revealed the medication Lorazepam was documented as not given at 8:00pm on 3/12/2025, 3/13/2025 at 8:00am and 8:00pm and on 3/14/2025 at 8:00am. Record review of CR#1's nurse's notes revealed medication Lorazepam 0.5mg was not given on 3/12/2025 at 8:00pm, 3/13/2025 at 8:00am and 8:00pm and on 3/14/2025 at 8:00 am due to the following Page 1 of 3 675996 675996 04/03/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Administration Notes, Lorazepam Oral Tablet 0.5 mg. Give 1 tablet by mouth two times a day for mental health was pending delivery. In an interview on 3/14/2025 at 2:50pm with LVN C she said she was the one who admitted CR#1. She said the Lorazepam was a controlled medication and needed a triplicate to be ordered. She said she called the Nurse Practitioner and gave her the order and she said she would call the pharmacy. She said she thought the medication was in the facility as no one said anything to her. At that point she said she was going to call the pharmacy. The pharmacy was called in the presence of the Surveyor, and they said the medication was on order, but they did not get permission from the doctor to dispense the medication. She then called the Nurse Practitioner and she said she called her office and asked them to call the medication in to the pharmacy and she did not know what happened. At that point the Nurse Practitioner said she was going to call the office. The Nurse Practitioner later called back and said the medication was never call into the pharmacy. Further interview with LVN C on 4/3/2025 at 11:30am she said that if the medication was not delivered then the nurse was expected to call the pharmacy and find out why it was not delivered. She said if at the end of the shift they did not get the medication then it should be passed on to the next shift and if things were not resolved they should inform the DON. In an interview with on 3/14/2025 at 5:15pm with LVN D she said she had gotten a report from the outgoing nurse regarding the order for CR#1 and she called the Nurse Practitioner and left a message, and she did not get a call back and she passed the message on to the day nurse. She said she did not know that the medication was not delivered because she was off. She said medications can be had from the E-kit but control medications need to get the pharmacist permission to dispense. She said if the medication was not acquired within a timely manner the DON should be notified. Interview on 04/03/2025 at 12:30 PM with the Director of Nursing she said if there was an order for controlled medication the physician or Nurse Practitioner should be called for them to call the triplicate to the pharmacy. She said if the medications were not received in a timely manner, the nurses are expected to inform the DON or the Administrator. She said residents not getting their medication in a timely manner could cause them to take longer to get well. She said she will be in-servicing the staff. Record review of the facility undated Pharmacy Services read in part . Policy Statement The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. Policy Interpretation and Implementation 1.Pharmaceutical services consists of: a. The processes of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding (e.g., intravenous antibiotics), dispensing, packaging, labeling, dis-tributing, administering, monitoring responses to, using and/or disposing of all medications, biologicals, chemicals; 675996 Page 2 of 3 675996 04/03/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0755 Level of Harm - Minimal harm or potential for actual harm 2.The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. 3.Pharmacy services are available to residents 24 hours a day, seven days a week Residents Affected - Some 4.Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. 5.Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. 6.Medications acquired or dispensed in this facility are FDA approved for use by the residents and meet the requirements established by the Federal Food, Drug and Cosmetic Act. 7.Medications are received, labeled, stored, administered, and disposed of according to all applicable state and federal laws and consistent with standards of practice. 8.Specific procedures governing pharmacy services are developed by the consultant pharmacist in collaboration with the medical director and the director of nursing services. c. Administration of medications. f. Documentation of processes, as applicable. 675996 Page 3 of 3