Carechoice Of Boerne

During an observation and interview of medication administration on 05/27/2026 from 10:05 a.m. to 10:18 a.m., LPN A was observed to start preparing Resident #4's medication administration at 10:05 a.m. On LPN A's electronic medication administration record screen, Resident #4's folic acid, Pepcid, allopurinol, iron, multiple vitamin-mineral tablet, thiamine HCl, Lexapro, metformin HCl, magnesium oxide, metoprolol tartrate, and zinc were observed to be scheduled for administration at 09:00 a.m. LPN A was observed to administer Resident #4's medications at 10:18 a.m. LPN A stated she was familiar with the facility's medication administration policy.

During an interview on 05/28/2026 at 04:11 p.m., the ADMIN stated, from his understanding, the time the staff had to administer a medication was they had an hour before and after the medication was scheduled, such as if the medication was scheduled at 08:00 a.m., they could administer the medication from 07:00 a.m. to 09:00 a.m. He stated that without knowing what the specific medication was for he could not determine the impact of a late medication administration, but if for example the medication was for pain, the late administration might result in experiencing pain before the pain was leveled off and the resident might become a little perturbed.

During an interview on 05/28/2026 at 04:40 p.m., the DON stated the nursing staff had an hour before and after the scheduled administration time to administer a medication per facility procedure.

She stated there could be an interruption on the floor that might delay or interrupt administration, but she would usually expect the staff to administer within the two-hour window.

She stated the impact of late medication administration would depend on the number of hours between the medications next administration and if the administration was late, it could result in the next administration issued too soon, which could affect the resident.

Record review of the facility's policy titled, Administering Medications, dated revised April 2019, revealed, Policy StatementMedications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation .4.

Medications are administered in accordance with prescriber orders, including any required time frame.5.

Medication administration times are determined by resident need and benefit, not staff convenience.

Factors that are considered include: a.

Enhancing optimal therapeutic effect of the medication; b.

Preventing potential medication or food interactions; and c.

Honoring resident choices and preferences, consistent with his or her care plan.7.

Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Record review of the facility's policy titled, Adverse Consequences and Medication Errors, dated 2001 and revised June 2025, revealed, Medication Errors.2.

Examples of medications [sic] errors include:. g. wrong time;.

675678 05/28/2026

Care Choice of Boerne 200 E Ryan St Boerne, TX 78006

Based on observations, interviews, and record review the facility failed to ensure all drugs and

authorized personnel to have access to the keys, for 1 of 3 medication carts (200-Hall medication cart) reviewed for security. LPN B left the 200-Hall medication cart unsupervised, unattended, and unlocked during a medication administration for approximately two (2) minutes on 05/27/2026 at 10:26 a.m.

This failure could place residents at risk for misappropriation of property and or not receiving the therapeutic effects of their medications.The findings included: During a medication administration observation on 05/27/2026 from 10:17 a.m. to 10:28 a.m., LPN B was observed to review and prepare Resident #3's medications for administration. At approximately 10:26 a.m., LPN B picked up Resident #3's prepared medications in a cup, left the 200-Hall cart in the 200-Hall next to Resident #3's room, facing out toward the hallway, and entered Resident #3's room.

The 200-Hall medication cart was observed to be unlocked and unattended.

There were no residents or visitors in the immediate area. LPN B was observed to administer Resident #3's medications at bedside and returned to the 200-Hall medication cart at 10:28 a.m.

During an interview on 05/27/2026 at 10:28 a.m., LPN B stated when she entered a resident's room, she would usually lock the cart.

She stated she did not realize she had not locked the cart.

She stated the impact of not locking the cart was that if a patient came by, they could open it up.

She stated the narcotics would have still been secured since they were locked separately and the punch cards that held most of the resident medications would have been difficult for the residents to get into.

During an interview on 05/28/2026 at 04:11 p.m., the ADMIN stated, to his understanding, the medication cart should be secured as soon as the nursing staff pull away from the medication cart. He stated the impact of not locking a medication cart was the safety of someone if they get access to the content of the cart.

During an interview on 05/28/2026 at 04:40 p.m., the DON stated her expectation for nursing staff was that they should lock the medication cart anytime they are walking away from the cart.

She stated the impact of not locking a medication cart was that medications could be unsecure and potentially accessed by a resident or anyone that should not have access to those medications.

Record review of the facility's policy titled, Administering Medications, dated revised April 2019, revealed, Policy StatementMedications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation .19.

During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed.