Health inspection·July 24, 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. Based on observations, interviews, and record review, 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 1 of 1 (100/200-Hall) medication room reviewed for pharmacy services. The facility failed to ensure expired medical supplies were removed from 100/200-hall medication storage room on 07/24/2025. This failure could place residents at risk of receiving medication using expired medical supplies, increased pain due to dull needles, and/or infection due to contamination of expired medical supplies. Findings included: Observation on 07/24/2025 at 11:13 AM of the 100/200-hall medication room revealed the following:One 24G x 3/4 in. safety IV catheter with an expiration date of 03/31/2024,One disposable syringe without needle with an expiration date of 11/10/2024,One 20G x 1 in. safety IV catheter with an expiration date of 12/22/2024,Three 1-ml tuberculin safety syringe with needle with expiration dates of 12/31/2024, andTwo hypodermic needle 25G x 0.625 with expiration dates of 07/16/2025. During an interview on 07/24/2025 at 11:16 AM, MA A stated the ADON was responsible for checking for expired medications and supplies in the 100/200-hall medication room. He stated expired supplies should not be used on residents. MA A stated he was unsure of the effect of using expired supplies on residents because the supplies found in the medication room were not supplies, he used on residents. During an interview on 07/24/2025 at 02:22 PM, the ADON stated she was responsible for checking the 100/200-hall medication room for expired medications and supplies. She stated she checked the medication room daily with her morning rounds. She stated the DON was her oversight and followed behind her to ensure completion of her work. The ADON stated if the expired supplies were used on the residents, the needles may not be as sharp, but she was unsure how the expired syringe could affect the residents. During an interview on 07/24/2025 at 02:42 PM, the DON stated the medication aides were responsible for checking for expired medications and supplies daily. She stated the ADON was responsible for following up to ensure no expired medications or supplies remained in the 100/200-hall medication room. The DON stated the expired supplies could be contaminated and potentially cause an infection to the residents if used. She stated the needles may be dull and could potentially cause an increase in pain with administration of medication. During an interview on 07/24/2025 at 03:10 PM, the ADMIN stated the ADON was responsible for checking for expired medications and supplies in the 100/200-hall medication room. The ADMIN stated she expected the nurses to be checking the 100/200-hall medication room also. She stated she expected the ADON and the nurses to check the medication room daily. The ADMIN stated the expired needles could potentially cause more irritation with injections if used beyond the expiration date on the residents. The ADMIN stated the syringes, or sterile supplies may have been contamination that could potentially lead to sickness if used on residents beyond the expiration date. Record review of the facility's, undated, policy titled Medication Access and Storage reflected: Policy:It is the policy of this facility to store all drugs and biological in Page 1 of 2 676459 676459 07/24/2025 Sedona Trace Health and Wellness Center 8324 Cameron Rd. Austin, TX 78754

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications:Procedures:.13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists. 676459 Page 2 of 2