Health inspection·December 8, 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 that assures the accurate acquiring, receiving, dispensing and administering of medications to meet the needs for one resident (Resident #1) of 5 residents reviewed for pharmacy services, in that: The facility failed to ensure Resident #1's narcotic medications were recorded in the EMR, showing they had been administered on 10/3/2025, 10/5/2025, 10/6/2025, and 10/8/2025. This failure placed residents at risk for medical errors, complications, decreased quality of life and hospitalization.Findings included:Review of Resident #1's face sheet dated 10/14/2025 reflected she was an [AGE] year-old-female admitted on [DATE] with diagnosis that included: acute respiratory failure (condition where the lungs cannot properly exchange gases), Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that cause long term breathing problems), atrial fibrillation (an abnormal heart rhythm), congestive heart failure (condition where the heart is weakened and cannot pump effectively), and hypertension (high blood pressure). Review of Resident #1's admission MDS assessment dated [DATE] reflected she had a BIMS score of 13 suggesting no cognitive impairment. Review of Resident #1's orders reflected an order dated 10/2/2025: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Pain DNE 3G/24HR. Review of Resident #1's narcotic count sheet for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) reflected that she had been given 1 tablet on the following dates and times:10/3/2025 at 10:00 am10/5/2025 at 3:00 pm10/5/2025 at 8:07 pm10/6/2025 at 2:15 pm10/8/2025 at 6:00 pm Review of Resident #1's October MAR reflected no administration entries for the following dates and times: 10/3/2025 at 10:00 am10/5/2025 at 3:00 pm10/5/2025 at 8:07 pm10/6/2025 at 2:15 pm10/8/2025 at 6:00 pm During an interview on 10/14/2025 at 1:00 pm, the ADM stated her expectation was that staff would do both parts for medication administration - click off the MAR and sign out in the narcotic book. She stated their policy stated staff were supposed to click off in the MAR when medications were administered. She stated if the MAR was not signed off, medication would be given too soon, and the facility would not have an accurate record of when medications are being given. During an interview on 10/14/2025 at 2:10 pm, the DON stated she had worked on the floor on 10/3/2025, and she had administered Resident #1 her narcotic medications at 10:00 am. She confirmed the signature on the narcotic count for 10/3/2025 was her signature. She stated she signed the medication out on the narcotic count sheet, but forgot to sign it off on the MAR. She stated she got pulled into a room where Resident #1 had requested medication before therapy, so she rushed it down to her without taking her medication cart with her. When she got back to her cart, another resident was already asking for something, and she forgot to document the administration on the computer in Resident #1's MAR. She stated her expectation as the DON was that staff - including herself - would document in the MAR and the narcotic count sheet when the medication was given. She stated if staff did not document in the MAR, a medication (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: 676289 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 676289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Atrium of Bellmead 2401 Development Blvd. Bellmead, TX 76705 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)