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F0755
E

Medication Administration and Storage Deficiencies

Tyler, Texas Survey Completed on 05-05-2025

Penalty

Fine: $419,660
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the accurate acquisition, receipt, dispensing, and administration of medications for one resident and failed to properly manage medication storage on one medication cart. Specifically, a medication aide administered calcium carbonate 500 mg tablets, crushed, to a resident instead of the prescribed calcium carbonate 750 mg with simethicone 250 mg chewable tablets, as ordered by the physician. The correct medication was not available on the medication cart, and staff were unaware if it was available elsewhere in the facility. The medication administration record was documented as if the correct medication had been given, despite the substitution. Additionally, expired medications, including acetaminophen, melatonin, and ondansetron, were found on the first-floor east hall nurse's medication cart. These expired medications had not been removed in accordance with facility policy, which requires immediate removal and disposal of outdated, contaminated, discontinued, or deteriorated medications. Interviews with staff confirmed that monthly reviews were expected, but expired medications remained accessible on the cart at the time of the survey.

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