Rambling Oaks Courtyard Extensive Care Community

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

dryness. She went inside the room and talked to the resident that she would get his nasal spray and would place them inside the cart. She also told the resident that she would request an order for his nasal spray. In

an interview on 09/02/2025 at 11:08 AM, LVN A stated she already took Resident #1's nasal spray and had placed an order for it. She said the nasal spray should be inside the nurses' cart and should be administered by nurses. She said the resident might be confused and took the medication using a different route. She said other residents, that were allergic to the content of the medication, might access the medication and consume it leading to allergic reactions. She said she also checked the rooms of other residents if there were medications inside the room. She said she would also coordinate with the family members to let the nursing staff know if they were bringing any medication. In an interview on 09/02/2025 at 11:50 AM, the DON stated Resident #1's nasal spray should be administered by nurses and there should be a physician's order for it. She said the expectation was for the staff to check if there were any medications inside the residents' room. She said if a resident was administering medications unsupervised, for this incident a nasal spray, there could be adverse effects if the nasal spray was overused such as nose irritation or allergic reactions. She said if the resident was the one administering the nasal spray, there should be an assessment that the resident was able to do so. She said if the resident was deemed able to administer his nasal spray, the nasal spray should still not be on top of the side table were other confused residents could assess it and consume it. The DON said that since the resident was using it, she would check if a physician order was already in place. The DON said she would do an in-service about not leaving any medication inside the residents' room and scanning the room if there were any medications accessible to the residents. In an interview on 09/02/2025 at 12:39 PM, the Administrator stated residents could not administer their own medications unless there was an assessment that the residents were competent enough to do it. She said the resident might overuse the medication resulting to the resident being overmedicated. She said the expectation was for the staff to scan the room if there were any medications at bedside. She said there would be some family members that would bring medications, but still, those medications should not be inside the room and the facility should be aware. She said she would coordinate with the DON on how to make sure that there were no medications inside the residents' room and that no resident was administering any medication by himself. Record review of the facility's policy, Medication Administration Procedures Pharmacy Policy & Procedure Manual 2003, revised 10/25/17 reflected, 1. All medications are administered by licensed medical or nursing personnel . 14. A specific order must be obtained from the Physician Record review of the facility's policy, Medication and Treatment Orders 2001 MED-PASS, Inc revised July 2016 reflected Policy Interpretation and Implementation . 1. Medications shall be administered only upon the written order . 3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rambling Oaks Courtyard Extensive Care Community

112 Barnett Blvd Highland Village, TX 75077

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited RAMBLING OAKS COURTYARD EXTENSIVE CARE COMMUNITY in HIGHLAND VILLAGE, TX for a deficiency under regulatory tag F-F0761 during a complaint investigation conducted on 2025-09-02.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 2 deficiencies cited during this inspection of RAMBLING OAKS COURTYARD EXTENSIVE CARE COMMUNITY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-03.