Brentwood Terrace: Missed Medication Doses Unreported - TX
The medication was Qulipta. The resident was identified in inspection records only as Resident 2. The nurses knew the supply had run out. Nobody did anything about it.
Federal inspectors cited the facility in November 2025 following a complaint investigation. The violation was tagged F0755, covering medication administration, and inspectors rated it as causing minimal harm or potential for actual harm.
The Director of Nursing said she had no idea it happened.
During an interview on November 12, nurses were supposed to call the pharmacy before a resident's medication ran out, the DON explained. If a dose was missed, the physician should have been contacted. If nurses couldn't resolve it, they should have come to her. None of that occurred. "Not administering medications as ordered by the physician could result in a negative outcome," she told inspectors.
The Administrator was equally direct about what he expected and equally unaware it had gone wrong. He said it was the nurse's responsibility to make sure medications were given as ordered. If they weren't, nurses should have notified the ADON and the DON immediately. He said he was not medically trained and therefore could not speak to the specific risks of missing doses of this particular drug. What he could speak to was the expectation: call the pharmacy, get the medication delivered, do not let it slide.
The nurse most directly connected to the missed doses, identified in the inspection record as LVN D, did not answer the phone when inspectors tried to reach her.
The facility's own written policy, Medication Administration and General Guideline version 3-2025, states that medications are administered as prescribed, in accordance with the written orders of the attending physician. The policy did not prevent the gap. The expectation that nurses would call the pharmacy did not prevent it. The chain of notification that runs from floor nurse to ADON to DON did not activate.
Resident 2 simply did not receive the medication their doctor had ordered, for days, and the people responsible for knowing about it did not know.
Qulipta is a prescription drug used to prevent migraine attacks. Missing doses does not carry the same immediate danger as skipping certain cardiac or seizure medications, which is reflected in the minimal harm rating inspectors assigned. But the rating describes what was documented, not what could have developed, and the DON herself said plainly that going without ordered medication could produce a negative outcome.
The more durable problem the inspection surfaces is not the gap in one resident's medication schedule. It is that the system designed to catch that gap, the nurse who calls the pharmacy, the nurse who calls the doctor, the nurse who tells the supervisor, failed at every step without anyone realizing it until inspectors arrived.
The Administrator said he expected nurses to notify supervisors when medications weren't given. The DON said nurses should have contacted her. Neither of them knew. The nurse who could have explained what happened did not pick up the phone.
Resident 2 went without their medication. The DON found out from the inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brentwood Terrace Healthcare and Rehabilitation from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 3, 2026 · Our methodology
BRENTWOOD TERRACE HEALTHCARE AND REHABILITATION in PARIS, TX was cited for violations during a health inspection on November 21, 2025.
The resident was identified in inspection records only as Resident 2.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.