Health inspection·November 13, 2023

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 to ensure accurate administration and documentation of medications for 2 of 12 residents (Residents #1 and #2) reviewed for pharmacy services and medication administration in that: The facility failed to administer medications as prescribed for Residents #1 and #2. This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. The findings included: Record review of the admission face sheet, dated 11/9/2023, reflected Resident #1 was a female initially admitted on [DATE], readmitted [DATE], with a diagnosis included: hypertensive heart disease without heart failure (high blood pressure without affecting the pumping action of the heart muscles), atherosclerotic heart disease of native coronary artery without angina pectoris (the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall without chest pain), peripheral vascular disease (slow and progressive circulation disorder), and essential hypertension (high blood pressure). Record review of the care plan with a start date of 11/7/2023, reflected Resident #1 had a Focus of The resident has hypertension (high blood pressure) with associated intervention of: Give anti-hypertensive medications as ordered. had a Focus of The resident has coronary artery disease r/t hypercholesterolemia with associated intervention of: Give all cardiac meds as ordered by the physician Give meds for hypertension Record Review of Resident #1's Order Summary Report dated 11/9/2023 revealed: Isosorbide Dinitrate Oral Tablet 30 MG, Give 1 tablet by mouth one time a day related to HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE Hold if SBP less than 110, DBP less than 60 or HR less than 60 and NIFEdipine Oral Capsule 10 MG, Give 3 tablets by mouth one time a day for HTN Administer 3 tablets to equal total dosage of 30mg Hold if SBP less than 110, DBP less than 60 or HR less than 60 Record review of the MAR for Resident #1 from 10/1/2023 to 10/31/2023, reflected the following medications were administered outside of parameters: Isosorbide Dinitrate Oral Tablet 30 MG, Give 1 tablet by mouth one time a day related to Page 1 of 3 455789 455789 11/13/2023 Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229

F 0755 HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE Hold if SBP less than 110, DBP less than 60 or HR less than 60 Level of Harm - Minimal harm or potential for actual harm *10/18/2023 0900: [SBP/DBP: 135/56 and HR: 48]; Residents Affected - Some *10/22/2023 0900: [SBP/DBP: 121/71 and HR: 53]; *10/28/2023 0900: [SBP/DBP: 133/74 and HR: 52] NIFEdipine Oral Capsule 10 MG, Give 3 tablets by mouth one time a day for HTN Administer 3 tablets to equal total dosage of 30mg Hold if SBP less than 110, DBP less than 60 or HR less than 60 *10/18/2023 0930: [SBP/DBP: 135/56 and HR: 48]; *10/29/2023 0930: [SBP/DBP: 120/70 and HR: 55] Record review of the admission face sheet, dated 11/9/2023, reflected Resident #2 was a male initially admitted on [DATE], readmitted [DATE], with a diagnosis included: pulmonary heart disease, peripheral vascular disease. Record review of the care plan reflected Resident #2 did not mention to Give all cardiac meds as ordered by the physician or Give meds for hypotension. Record Review of Resident #2's Order Summary Report dated 11/9/2023 revealed: Midodrine HCl Oral Tablet, Give 15 mg by mouth three times a day for Hypotension Hold if SBP greater than 120. Record review of the MAR for Resident #2 from 11/1/2023 to 11/9/2023, reflected, the following medication being administered outside of parameters on: Midodrine HCl Oral Tablet, Give 15 mg by mouth three times a day for Hypotension Hold if SBP greater than 120 *11/1/2023 1100: [SBP 129]; *11/3/2023 2200: [SBP 136]; *11/9/2023 1100: [SBP 123] During interview on 11/13/2023 at 10:14 AM, the ADON A revealed that Resident #1 was incorrectly given Isosorbide Dinitrate and Nifedipine on October 28th and 29th , confirming blood pressure was outside of parameters and should not have received heart medications. The ADON A further revealed that Resident #2 was incorrectly given Midodrine on October 26th, 28th, and 30th because blood pressure was outside of parameters. During an interview on 11/13/2023 at 10:58 AM, the LVN A verified that Midodrine was administered to Resident #2 outside of blood pressure parameters on October 26th, 28th , and 30th. During an interview on 11/13/2023 at 1:26 PM, the DON revealed that the nurses were administering heart medications outside of blood pressure parameters. 455789 Page 2 of 3 455789 11/13/2023 Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229

F 0755 Level of Harm - Minimal harm or potential for actual harm Record Review of Administering Medications policy, revised April 2019, reflected the following step in the preparation stage: 4. Medications are administered in accordance with prescriber orders . and 11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary. Residents Affected - Some 455789 Page 3 of 3