Health inspection·August 29, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 5 residents (Residents #1 and #2) reviewed for pharmacy services. 1. The facility failed to administer Resident #1's Losartan per the recommended and prescribed blood pressure parameters in July and August of 2025. 2. The facility failed to administer Resident #2's Isosorbide per the recommended and prescribed blood pressure parameters in July and August of 2025. These failures could place residents at risk for complications, as well as jeopardize their health and safety.Findings included: Record review of Resident #1's face sheet, dated 08/26/2025, revealed a [AGE] year-old female with an original admission date of 04/17/2018, and a current admission date of 11/02/2023. Pertinent diagnoses included Alzheimer's Disease (progressive decline in memory, thinking, and behavior), cognitive communication deficit (difficulty in communication which arises from impaired cognitive functions), Dementia (a group of symptoms affecting memory, thinking, and social abilities), and Essential Primary Hypertension (high blood pressure which occurs without an identifiable medical condition causing it). Record review of Resident #1's Quarterly MDS assessment, dated 08/12/2025, revealed a BIMS score of 01, which revealed severely impaired cognition. MDS also revealed an active diagnosis of Hypertension. Record review of Resident #1's care plan, last reviewed 08/23/2025, revealed a care plan for potential for hyper/hypotensive episodes related to Hypertension and antihypertensive medications. Interventions included give medications as ordered, and/or report abnormal blood pressures to doctor. Record review of Resident #1's active physician orders, started 03/29/2025, revealed an order for Losartan Potassium (a medication used to treat high blood pressure) 50 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Record review of Resident #1's July 2025 MAR revealed Losartan Potassium 50 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Dates when Losartan was given outside of parameters included: 07/05/2025 7:00 AM B/P 113/65 Administered 07/11/2025 6:00 PM B/P 119/70 Administered07/13/2025 7:00 AM B/P 106/68 Administered07/22/2025 7:00 AM B/P 110/75 Administered07/27/2025 6:00 PM B/P 102/66 Administered07/28/2025 6:00 PM B/P 102/78 Administered Record review of Resident #1's August 2025 MAR revealed Losartan Potassium 50 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Dates when Losartan was given outside of parameters included: 08/11/2025 7:00 AM B/P 116/60 Administered08/16/2025 7:00 AM B/P 110/60 Administered08/16/2025 6:00 PM B/P 118/62 Administered08/23/2025 7:00 PM B/P 117/66 Administered Record review of Resident #2's face sheet, dated 08/27/2025, revealed an [AGE] year-old male with an original admission date of 04/03/2024. Pertinent diagnoses included Alzheimer's Disease (progressive decline in memory, thinking, and behavior), cognitive communication deficit (difficulty in communication which arises from impaired cognitive functions), Dementia (a group of symptoms affecting memory, thinking, and social abilities), and Essential Primary Hypertension (high blood pressure which occurs Residents Affected - Few Page 1 of 3 455455 455455 08/29/2025 Meridian Care of Alice 218 219 N King St Alice, TX 78332

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few without an identifiable medical condition causing it). Record review of Resident #2's Change in Condition MDS assessment, dated 07/27/2025, revealed a BIMS score of 07, which revealed severely impaired cognition. MDS also revealed an active diagnosis of Hypertension. Record review of Resident #2's care plan, last reviewed 08/06/2025, revealed a care plan for medication to treat hypertension. Interventions included give medications as ordered and monitor blood pressures as ordered and notify doctor if results are high or low. Record review of Resident #2's active physician orders, started 03/05/2024, revealed an order for Isosorbide Mononitrate (a medication used to treat high blood pressure) 60 MG, give one tablet by mouth daily; Hold if systolic blood pressure was less than 120. Record review of Resident #2's active physician orders, started 09/15/2024, revealed an order for Losartan Potassium 25 MG, give one tablet by mouth twice daily for hypertension; Hold if systolic blood pressure was less than 120. Record review of Resident #2's July 2025 MAR revealed Losartan Potassium 25 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Dates when Losartan was given outside of parameters included: 07/01/2025 7:00 AM B/P 115/64 Administered 07/12/2025 6:00 PM B/P 107/61 Administered Record review of Resident #2's July 2025 MAR revealed Isosorbide Mononitrate 60 MG, give one tablet by mouth daily; Hold if systolic blood pressure was less than 120. Dates when Losartan was given outside of parameters included: 07/01/2025 7:00 AM B/P 115/64 Administered 07/12/2025 7:00 AM B/P 107/61 Administered Record review of Resident #2's August 2025 MAR revealed Losartan Potassium 25 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Dates when Losartan was given outside of parameters included: 08/01/2025 7:00 AM B/P 118/81 Administered 08/06/2025 7:00 AM B/P 119/75 Administered08/11/2025 7:00 AM B/P 110/66 Administered08/15/2025 7:00 AM B/P 116/76 Administered08/22/2025 7:00 AM B/P 119/79 Administered Record review of Resident #2's August 2025 MAR revealed Isosorbide Mononitrate 60 MG, give one tablet by mouth daily; Hold if systolic blood pressure was less than 120. Dates when Losartan was given outside of parameters included: 08/01/2025 7:00 AM B/P 118/81 Administered 08/04/2025 7:00 AM B/P 119/71 Administered08/06/2025 7:00 AM B/P 119/75 Administered08/11/2025 7:00 AM B/P 110/66 Administered08/15/2025 7:00 AM B/P 116/76 Administered08/22/2025 7:00 AM B/P 119/79 Administered In an interview on 08/27/25 at 12:12 PM, LVN-B stated he thought he got confused and probably messed up while administering blood pressure medication since there were multiple medications with multiple different parameters. He stated he always checked the residents' blood pressures when they got blood pressure medication, and then he always checks parameters for the medication, but he must have gotten confused. LVN-B stated the blood pressure was checked to make sure it was within range, because if they give a medication for hypertension when the blood pressure was already low, it could continue to drop, and the patient could bottom out. If the blood pressure dropped too low it could cause the resident serious harm. LVN-B denied having any residents experience hypotensive crisis or episodes in the past couple of months. He stated he had been educated and in-serviced regarding administering blood pressure medications, as well as taking vital signs. In an interview on 8/27/25 at 1:25 PM, RN-C stated she always checked the parameters in the orders, but thought she just missed some because the blood pressures taken were close to the ordered parameters. She stated she should have been more careful and paid more attention. RN-C stated the blood pressure was assessed to see if it was too high or too low. RN-C stated if antihypertensive medication was given when the blood pressure was already low, it could cause the resident to have a hypotensive crisis. She stated she had not seen any residents have any signs or symptoms of hypotension in the past couple of months. RN-C stated the blood pressure should always be checked and compared to the parameters prior to administering any blood pressure medication so a resident was not harmed. In an 455455 Page 2 of 3 455455 08/29/2025 Meridian Care of Alice 218 219 N King St Alice, TX 78332

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview on 8/27/25 at 1:49 PM, LVN-D stated nurses should always check the parameters in the orders prior to administering a blood pressure medication because if it was given outside of parameters, it could cause harm, or even death, to a resident. He stated he did not remember the last time he was in-serviced regarding blood pressure medications or vital sign parameters, but he thought it was around two years ago. Record review of the facility's Administering Medications policy, revised April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. 11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary. 455455 Page 3 of 3