Health inspection·April 25, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 4 residents reviewed for pharmacy services. (Resident #1) The facility failed to ensure Resident #1 was administered her diltiazem (medication used to treat high blood pressure) and lisinopril (medication used to treat high blood pressure) 7 days in the month of March 2024. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings Include: 1. Record review of an undated face sheet indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), aphasia (language disorder that affects a person's ability to understand and express language, reading, and writing), cognitive communication deficit, heart disease, and atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). Record review of the physician orders dated 3/25/24 through 4/25/24 indicated Resident #1 had an order for diltiazem 240mg daily starting 1/31/23 with special instructions to hold for systolic blood pressure (the first number in a blood pressure reading and it measures the pressure in the arteries) less than 100 and heart rate less than 55. The progress notes indicated Resident #1 had an order for lisinopril 5mg daily starting 1/15/23 with special instructions to hold for systolic blood pressure less than 100 and heart rate less than 55. Record review of the MAR dated 3/1/24 through 3/31/24 indicated Resident #1 did not receive he diltiazem 240mg on 3/1/24, 3/3/24, 3/7/24, 3/24/24 and 3/26/24 due to condition. The MAR indicated Resident #1 did not receive her diltiazem 240mg on 3/20/24 and 3/25/24 due to drug/item unavailable. The MAR indicated Resident #1 did not receive her lisinopril 5mg on 3/1/24, 3/3/24, 3/7/24, 3/24/24, and 3/26/24 due to condition. The MAR indicated Resident #1 did not receive her lisinopril on 3/6/24 and 3/11/24 due to drug/item unavailable. Record review of Resident #1's vital table dated 3/1/24 through 3/31/24 indicated her blood pressures and heart rates for 3/1/24, 3/3/24, 3/6/24, 3/7/24, 3/11/24, 3/20/24, 3/24/24, 3/25/24, and 3/26/24 were as follows: Page 1 of 3 455678 455678 04/25/2024 Avir at Longview 301 Hollybrook Dr Longview, TX 75605

F 0755 3/1/24 - no blood pressure recorded; no heart rate recorded. Level of Harm - Minimal harm or potential for actual harm 3/3/24 - no blood pressure recorded; no heart rate recorded. 3/6/24 - blood pressure 167/99; heart rate 62. Residents Affected - Some 3/7/24 - no blood pressure recorded; no heart rate recorded. 3/11/24 - no blood pressure recorded near time medication administration scheduled for; no heart rate recorded near time medication administration scheduled for. 3/20/24 - blood pressure 142/89; heart rate 78. 3/24/24 - no blood pressure recorded; no heart rate recorded. 3/25/24 - blood pressure 132/71; heart rate 69. 3/36/24 - no blood pressure recorded; no heart rate recorded. 3/27/24 - blood pressure 124/60; heart rate 72. Record review of the pharmacy packing slip dated 3/18/24 indicated Resident #1's diltiazem 240mg was delivered with a quantity of 30 to the facility. Record review of an undated emergency kit medication inventory indicated the facility had lisinopril 10mg tablets and lisinopril 2.5mg tablets available in their emergency kit. Record review of the MDS dated [DATE] indicated Resident #1 was rarely/never understood by others and rarely/never understood others. The MDS did not indicate Resident #1's BIMS score. Record review of the care plan last revised on 4/18/24 indicated Resident #1 experienced labile hypertension (when the blood pressure suddenly rises and then returns to normal, often due to emotional stress) with interventions including administer medications as ordered. During an interview on 4/25/24 at 12:48 p.m. MA A said if a MAR indicated a medication was not administered: due to condition it was because a blood pressure was too low. MA A said if a blood pressure was too low, she did not document what the blood pressure was just not administered: due to condition. MA A said without a note or documentation there was no way to see what the condition was that caused the medication not to be administered. MA A said if it was recorded on the MAR not administered: drug/item not available it meant they did not have the drug in the facility. MA A said nurses were the only ones who could access the emergency kit. During an interview on 4/25/24 at 12:50 p.m. LVN B said if a blood pressure or blood sugar was out of parameters when she put in the MAR not administered: due to condition it gave an option for other and a place to add notes about what the condition was. LVN B said the medication aides usually reported to the nurses when a medication was not given, and the nurse documented it not being given and why in the progress notes. During an interview on 4/25/24 at 2:38 p.m. the DON said when administering a blood pressure 455678 Page 2 of 3 455678 04/25/2024 Avir at Longview 301 Hollybrook Dr Longview, TX 75605

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication, she expected staff to ensure there are parameters for blood pressure medication, check the resident's blood pressure, and report to the nurse if the blood pressure was outside of the parameters. The DON said she expected all blood pressures taken prior to administration of medication to be documented somewhere so if a medication had to be held several times there was a way to know why it was being held. The DON said MAs should report blood pressures outside of parameters to the nurse so the nurse can follow up on the resident. The DON said if it was not documented why a medication was held there was no way to go back and find out why it was held. The DON said the importance of documenting why medications were held was to be able to recognize acute changes in a resident. During an interview on 4/25/24 at 3:01 p.m. the DON said there were no progress notes for Resident #1 for the month of March except for one regarding COVID testing. Record review of the facility's Administering Medications policy dated 4/22/22 indicated, Medications shall be administered in a safe and timely manner as described .Medication must be administered in accordance with the orders, including any required time frame .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR in the space provided for that drug dose . 455678 Page 3 of 3