Health inspection·September 17, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the interdisciplinary team determined self-administration of medication was safe for 1 (Resident # 1) of 8 resident's reviewed for medication self-administration. The facility failed to prevent Resident #1 from possessing and administering an inhaler without an assessment to determine if she could safely self-administer the medication. This failure could place all residents who self-administer medications at risk of not receiving the therapeutic dose of their medication as ordered. Findings included: Record review of Resident # 1's face sheet dated 09/17/25, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy (a condition where the brain's function is impaired due to an imbalance in the body's metabolism), hypertension (high blood pressure), and malignant neoplasm of lower lobe left lung (lung cancer). Record review of Resident #1's admission MDS assessment dated [DATE], revealed Resident #1 was cognitively intact with a BIMS score of 13 and required partial to moderate assistance with most ADLs. Record review of Resident #1's care plan dated 09/03/25, revealed the resident had a recent decline in ADL self-performance related to Lupus, COPD, weakness and debility. Interventions included limited assistance and supervision by staff with ADLs. Record review of Resident #1's assessments in her EHR, revealed there was not an assessment for self-administration of medication. Record review of Resident #1's physician orders dated 08/30/25, revealed there was not an order for the resident to self-administer her own medications. In an observation and interview on 09/16/25 at 11:05 AM with Resident #1, revealed she was sitting in a chair next to the over bed table with personal items and a rescue inhaler that was on the over bed table at her beside and was unsecured. The inhaler observed on the over bed table was Albuterol Sulfate 90mcg/actuation (a rescue inhaler used to treat or prevent bronchospasm (narrowing of the airways). There were no further instructions listed on the inhaler. Resident # 1 stated it was a rescue inhaler that she kept with her. In an observation and interview on 09/16/25 at 3:35 PM with Resident #1, revealed a rescue inhaler was positioned on the over bed table and not secured. Resident #1 stated that she brought the inhaler with her from home and the instructions said she could use it as needed up to 4 times per day, but that she only allows herself to use it twice per day. She stated she takes Trelogy (a prescription medicine used long term to treat COPD) once per day and the one on the table was a rescue inhaler. In an interview on 09/16/25 at 3:45 PM with RN Charge Nurse A, revealed that she had been employed with the facility since May of 2025. She stated she took care of Resident #1 and did not have any residents on her hall that self-administered their own medication. She stated there is a risk if residents had medications at the bedside, they would have to have an assessment completed and an order from the physician. During the interview with RN Charge Nurse A, she reviewed the MAR for Resident #1 and stated that there was a PRN order for the Albuterol but according to the MAR, Resident #1 had never requested the medication. RN A stated that the negative effects of any resident having medications at their bedside Residents Affected - Few (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: 676135 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 676135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Village North Special Care Ctr 8600 Skyline Dr Dallas, TX 75243 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)