Health inspection·August 27, 2023

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #1's, August 2023 Medication Administration Record (MAR) indicated an order of Meropenem 1 GM (gram) to be reconstituted and administered every 8 hours. The medication was started on 08/21/2023 at 04:00pm. Record review of Resident #1's progress notes dated 08/24/2023 at 10:09AM reflected, This nurse administered the wrong medication (Zosyn) NP notified .who gave the following orders. Benadryl 25 mg, Prednisone 40 mg and Pepcid 20 mg Further a note dated 08/24/2023 at 04:50 PM revealed, .redness noted to face, neck torso and back warm to touch hand and fingertips cool to touch and discolored B/P 78/52 NP in the facility notified of change in skin color NP assessed the resident . order received to transfer to hospital for eval and treatment . Record review of the NP witness form with the date of interview on 08/25/2023 revealed, NP had gone to see Resident #1 for a follow up on UTI, IV pump was beeping LVN A walked after her. After the LVN A disconnected the IV tubing from Resident #1 it revealed a different name on the antibiotic bag, and it was a different medication (Zosyn) that the resident was allergic to. Mild flushing/purplish discoloration to both hands was noted. NP informed the residents primary care provider and orders were placed for the resident. LVN A reported of low B/P and IVF bolus was started but the B/P kept declining and at the time Resident #1 had widespread redness to her back, trunk, neck/face. Body was warm to touch by the extremities; hands, fingers and toes were cold and clammy and pale with purple discoloration. The resident condition was discussed by the primary care provider and the resident was transferred to the hospital. In an interview on 08/27/2023 at 12:35 PM with LVN A he stated he was the nurse in charge for Resident #1. He stated on 08/24/2023 he had administered Resident #1's IV antibiotic around 10 am. LVN A stated when he went to disconnect the IV tubing the NP was in the room with the resident and LVN A realized he had administered the resident a wrong medication which she was allergic to. The NP assessed the resident and ordered Benadryl, Pepcid and prednisone for Resident #1. NP also instructed for the resident to be monitored closely and obtain the resident's vital signs every 15 minutes. LVN A stated the resident was also administered IV (Intravenous) fluids due to low blood pressure, but it did not improve and the NP who was still in the facility. Resident #1 was then transferred to the local hospital for evaluation and treatment. LVN A stated he acknowledged his mistake, he stated he failed to check and make sure he picked the right medication and administered to the right resident. He stated even before starting the IV antibiotic he was supposed to double check again to make sure he was administering the right medication, but he didn't. LVN A stated administering the wrong medication to the resident which she was allergic to could have caused severe allergic reactions and even death. LVN A stated after the incident he received disciplinary action, he was in-serviced on medication administration, and he had a training to complete before returning to work. In an interview on 08/27/2023 at 12:48 PM with ADON revealed she was made aware of the incident on 08/24/2023 around lunch time. Immediately the ADON went and checked on another resident who was on antibiotic therapy on the same hall that LVN A was in charge and revealed the resident had received the right medication. ADON stated Resident #1 was monitored closely until it was determined she was to be transferred to the local hospital. ADON stated she expected the nurse to administer the medication to the right resident and right order. The ADON stated administering wrong medications that the resident was allergic to could cause death and severe allergic reactions. In an interview on 08/27/2023 at 1:35 PM with the Administrator revealed she was made aware of the incident on 08/24/2023 on the day it happened, and she started the investigation. Administrator reported the incident HHS on 08/26/2023. Administrator stated LVN A reported to her on 08/24/2023 that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675033 If continuation sheet Page 2 of 3 Printed: 05/15/2026 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 675033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Tree Nursing Center 434 Paza Dr Mesquite, TX 75149 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)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few he had administered the wrong medication to Resident #1, and the resident was allergic to the medication that was administered. The NP was with Resident #1 on 08/24/2023 at the time it was identified Resident #1 received the wrong medication. NP assessed the resident and ordered medication for the resident. The resident did not display any acute distress, but she had redness to her body and later her blood pressure dropped. NP recommended the resident to be transferred to the local hospital due to the decline in her blood pressure. LVN A received disciplinary action, he was in-serviced on medication administration and had to complete medication administration training. Administrator stated she expected LVN A to administer the right medication to the right patient. She stated administering the wrong medication could cause severe allergic reactions and even death to a resident who was allergic to the medication. There was no resident in the facility on IV therapy. Administrator stated after the incident all the medication aide and nurses were in-serviced on medication administration. Review of the facility policy dated 01/09/2014, titled Medication - Treatment Administration and Documentation Guideline reflected, 1. Verify labels accurately reflect the physician orders on the Electronic Medication Administration Record (EMAR) and Electronic Treatment Administration Record (ETAR) prior to administering patient medications and treatments. 2. Verify administration accuracy by checking the medication with the EMAR three (3) times. Measures that were put in place after the incident and the records were provided and reviewed. All medication aide and nurses were in-serviced on medication administration on 08/24/2023 LVN A will complete a four-week med pass with the ADON LVN A will complete a training on medication administration Two nurses will clarity the orders before medication administration LVN A received a disciplinary action dated 08/24/2023 During an interview on 08/27/2023 between 12:00 PM and 2:30 PM with the charge nurses who were on duty revealed they had been in-serviced on 08/24/2013 on medication administration. Review of IV therapy administration revealed the nurses had completed the training together with LVN A dated 08/27/2023 On 08/27/2023 at 3:15 PM, the administrator was notified of the PNC IJ. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675033 If continuation sheet Page 3 of 3