Health inspection·December 23, 2025

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 assure the accurate acquiring and administering of all drugs to meet the needs of the residents, for one resident (R#1) of three residents reviewed for pharmacy services. The facility failed to ensure physician ordered, Ingrezza 80 mg (a medication treatment of tardive dyskinesia) was provided as scheduled on [DATE], [DATE], [DATE] and [DATE]. This failure placed residents at risk for harm by not receiving the therapeutic effects of this medication prescribed. The findings were:Record review of R#1's face sheet dated [DATE] revealed R#1 was 68 years-old female and was admitted to the facility on [DATE]. R#1's diagnoses included Pneumonia (infection of the lungs), Acute respiratory failure (not enough oxygen in the body), anxiety disorder (excessive feelings of fear). Record review of R#1's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed R#1 BIMS score could not be determined and resident's mental status has not changed. The resident was dependent and was using a feeding tube. The resident's orders include Anticonvulsant, Antianxiety and Antipsychotic medicationsRecord review of R#1's care plan, dated [DATE], revealed R#1 was at risk for changes to mood due to diagnoses of schizoaffective disorder, anxiety and insomnia. The resident rarely understood and rarely understood others. Record review of R#1's Orders dated [DATE],revealed the following order: Ingrezza (valbenazine) 80 Mg with an order date of [DATE] and a start date of [DATE].An observation of R# 1 on [DATE] at 10:57 AM was conducted. R#1 was lying in bed and appeared to have involuntary body movements. R# 1 was being fed, hydrated and medicated by a tube. The resident was unable to express herself verbally.An interview with R#1 Family on [DATE] at 12:28 PM was conducted. R#1 Family revealed that R#1 was not given her medication as prescribed by the Doctor. R#1 Family stated, the nursing staff had not provided the medication because they had not ordered it.An interview with the Pharmacy Technician on [DATE] at 2:37 PM was conducted. The Pharmacy Technician stated the DON called the pharmacy on [DATE] at 11:01 AM and verbally ordered Ingrezza 80mg for R#1. The Pharmacy Technician advised the DON that a signed order must be received by the pharmacy before the prescription would be filled. The Pharmacy Technician emailed a form to the DON. The Pharmacy Technician stated that the DON sent a faxed, signed order on [DATE] at 6:39 AM. The Pharmacy Technician stated, on [DATE] at 10:15 AM the pharmacy faxed to the facility a report that the prescription was not in stock and that the pharmacy had ordered it from their vendor and it should be in [DATE] approximately 8 AM.An interview with the Pharmacist on [DATE] at 8:19 AM was conducted. The Pharmacist confirmed that the DON had been advised by the Pharmacy Technician that the DON would need to submit a signed order for that prescription. The Pharmacist also confirmed the order wasn't received until [DATE] at 6:39 AM and that the prescription was not in stock and it had been ordered from the manufacturer when the order was received. The Pharmacist stated, R#1 was administered medications via a feeding tube and there were no alternative medications that could be administered by the Page 1 of 2 676308 676308 12/23/2025 San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few feeding tube. An interview with the DON on [DATE] at 2:15 PM was conducted. The DON stated the orders for Ingrezza 80 mg were written by the Doctor on [DATE] with a start date of [DATE]. The DON stated, she had placed a verbal order to the pharmacy on [DATE] and she was asked by the Pharmacy Technician for a written, signed order. The DON stated, she sent the written, signed order and she didn't find out that the pharmacy did not have the prescription in stock until Monday morning [DATE]. The DON stated she placed a follow up call to the pharmacy on [DATE] and she was told the prescription had been ordered from the manufacturer and the expectation was that it would arrive on [DATE]. The DON stated she could not preorder the medication because R#1 did not have prescription coverage until [DATE].An Interview with the Doctor on [DATE] at 4:01 PM was conducted. The Doctor stated he ordered Ingrezza 80 mg. for R#1 on [DATE] with a start date of [DATE]. The Doctor stated he was working with the Manufacture Representative to try and get samples delivered to the facility as soon as possible. The Doctor stated if R#1 did not get her medication her symptoms from Tarda Dyskinesia would return. The Doctor stated, We have studied this medication, and the patient would not have any escalation of symptoms if she did not get this medication. The Doctor confirmed he could not prescribe an alternative medication for R#1's condition because this was the only one of its kind that can be administered via a feeding tube.Record review of the Nursing Policies and Procedures Medication Management Program revised [DATE], revealed medications are administered no more than one hour before to one hour after the medication pass time.Record Review of PHARMACY SERVICES POLICIES AND PROCEDSECTION 7 - MEDICATION PROCUREMENTSUBJECT: 7.1.0 ACQUISITION OF ROUTINE MEDICATION ORDERSPOLICY:1. The facility must provide or obtain routine medications and biologicals to meet the needs of each resident.PROCEDURES1. New admission / readmission / New OrdersA. For hard-copy medical records, ensure that all medications and biological orders are written, dated and signed by the Physician/Prescriber lawfully authorized to give such an order. B. Fax hard copy physician/prescriber orders to the pharmacy, whenapplicable 676308 Page 2 of 2