Health inspection·November 5, 2024

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 record reviews and interviews, 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 each resident for two (Resident #1 and Resident #2) of 2 residents, reviewed for pharmaceutical services, in that: Medications must be released to residents only on the written or verbal authorization of the attending physician. When a resident is transferred directly to another nursing facility or discharged to home, the resident's medications must be released to the new facility or to the resident or his family, respectively. The facility failed to provide the correct medications to Resident #1 upon discharge and failed to provide the correct medication to Resident #2 upon discharge. The facility nurse failed to check for correct medication before releasing to the resident and/or family member. This failure could place residents at risk for the consequences of drug diversion. The findings included: Record review of Resident #1's face sheet dated 11/05/2024, revealed she was admitted [DATE] with diagnosis Other Acute or Osteomyelitis, Right Ankle and Foot (Bone Infection); Methicillin susceptible Staphylococcus Aureus Infection as the cause of Diseases Classified (A group of [NAME]-positive bacteria that are genetically distinct from other strains of Staphylococcus, MRSA) Essential (Primary) Hypertension (High blood pressure that is multi-factorial and doesn't have one distinct cause). Record review on 11/05/2024 revealed Resident #1's medication list dated 09/30/2024 from the Summary of Episode Form and the Physician Orders noted no narcotics included on the Physician orders. Record review of Resident #2's face sheet dated 11/05/2024, revealed she was admitted [DATE] with diagnosis Acute Respiratory Failure with Hypoxia (occurs when the body does not have enough oxygen in the tissues); Malignant (Primary) Neoplasm, Unspecified (A rare cancer diagnosis that occurs when the origin of the cancer is unknown); Benign Neoplasm of Meninges, unspecified (A benign tumor in the meninges, which are the membranes that cover and protect the brain and spinal cord). Record review on 11/05/2024 revealed Resident #2's medication list dated 09/30/2024 from the Summary of Episode Form and the Physician Orders noted no narcotics included on the Physician orders. Page 1 of 3 676405 676405 11/05/2024 Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In a telephone interview on 11/04/2024 at 12:45 p.m. with Resident #1's family member A revealed that resident was discharged home with family member A on 09/30/2024 with medication. Family member A reported a complaint to HHSC that the medication sent home with Resident #1 was not her medication. Family member A provided photos of medication with Resident #2's name on them. Family member A called facility and reported the mistake to the facility. The facility sent prescriptions to the pharmacy for Resident #1. The facility has not picked up the medication. In a telephone interview on 11/05/2024 at 11:26 a.m. with Resident #2's family member B revealed that the medication that had been placed in the bag by the facility nurse belonged to another resident. Resident # 2 was transferred to an assisted living on 09/30/2024. Family member B stated that she returned the medication to the facility and was given the correct medication. Facility documented the medication return on 10/01/2024. Resident # 2 did not go without any medication. List of medications were included in the Summary of Episode Note included with Resident #2's discharge paperwork. In an interview on 11/05/2024 at 1:00 p.m. with the ADM revealed that he and the DON were aware of the medication mix-up. They immediately corrected the medication diversion by making sure orders were sent to pharmacy for Resident #1. Resident #1 still is in possession of Resident #2's medication. ADM revealed that there have been numerous attempts to get in touch with the family member A. ADM stated before the end of the day today, the SW was able to get in touch with family member A and Resident #2's medication will be picked up tomorrow from Resident #2's family member A. Review of facility's policy titled Discharge Medication, dated December 2016, reflected in part: Unless otherwise specified by facility policy, or contrary to current law or regulation, medications shall be sent with the resident upon discharge. Controlled substances may not be Released upon discharge. 1. A Physician must be contacted for an order to discharge resident with medications before they will be dispensed. 2. The Charge Nurse shall verify the medications are labeled consistent with current physician order including instructions for use. 3. Controlled substances shall not be released upon discharge of the resident unless permitted by current state law governing the release of controlled substances and as authorized (in writing) by the resident's attending Physician. 4. The nurse will reconcile pre-discharge medications with the resident's post-discharge medications. The medication reconciliation will be documented. 5. 676405 Page 2 of 3 676405 11/05/2024 Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021

F 0755 The nurse shall review medication instructions with the resident, family member or representative before the resident leaves the building . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676405 Page 3 of 3