Health inspection·August 16, 2023

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 on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 4 residents (Resident #39) reviewed for pharmacy services. The facility did not ensure medications were properly administered to Resident #39. This failure could place residents at risk for the unsafe administration of medications and not receiving prescribed doses of ordered medications. Findings: Record review of facility face sheet dated 8/15/2023 indicated Resident #39 was admitted on [DATE] with diagnoses of respiratory failure with hypoxia (low oxygen level) and end stage renal disease. Record review of quarterly MDS dated [DATE] revealed Resident #39 had a BIMS of 12 indicating mild cognitively impairment. Record review of comprehensive care plan dated 06/28/2023 did not indicate Resident # 39 could safely self-administer medications. Record review of physician order dated 9/13/2020 indicated Resident #39 took Carafate 1 gram 1 tablet by moth four times a day. Physician order dated 6/12/2023 indicated Resident #39 took Sevelamer 800mg 1 tablet by mouth three times a day. During an observation on 08/14/23 at 09:50 am Resident # 39 had a medicine cup with 2 tablets present: 1 white imprinted with R789 and 1 pink imprinted with 1712. Resident #39 stated he was asleep, and the worker left the medicine for him to take. Resident #39 stated the staff handed him the medicine cup and did not watch him take his medicine. During an interview on 8/14/2023 at 12:36 pm MA A stated she had been a medication aide since 1995 and employed at the facility for 8 years. She stated she gave Resident # 39's medicine and she watched him turn the medicine cup up to his mouth before she walked out of the room but did not ensure he took them. She stated the medicines in the medicine cup were Carafate and sevelamer. She stated she had been trained on proper medication administration and ensuring residents took their medicine and by not doing so could affect the resident or other residents if they were to take medicine that was left in the room. Page 1 of 2 676257 676257 08/16/2023 Trucare Living Centers 2265 S Sycamore St Palestine, TX 75801

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 08/15/23 at 8:38 am the DON stated she and the ADON were responsible for all training and MA A had been properly trained on medication administration. She stated she expected all staff passing medications ensured medications were taken by the resident and by not doing so could cause the resident not to get the benefit of their medicine or another resident could take them. During an interview on 8/16/2023 at 9:48 am the Administrator stated the medication aide and nurses were to make sure all medications were taken before leaving the resident's room. She stated she expected no medications were left at the bedside to prevent an adverse event from occurring with the resident. Record review of Personnel Competency Review dated Second Quarter 2023 for Med Pass indicated in checklist, Resident is observed to ensure medication is swallowed. Record review of medication pass audit dated 2/10/2023 indicated, 24. Medication is not left at the bedside Record review of facility policy titled Administering Medications dated 11/25/2017 indicated, .Medications shall be administered in a safe and timely manner . 676257 Page 2 of 2