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** The facility
failed to ensure that Resident #2's, medication Metoprolol for high blood pressure was given as ordered by
the physician.
Residents Affected - Few
This failure could place residents who received medications at risk of not getting their medications as
ordered which could result in resident not receiving the therapeutic benefits of the medication for blood
pressure which could result in decreased quality of life.
Findings included.
Resident #2
Record review of Resident 2#'s admission face sheet dated 05/15/2024 revealed she was a [AGE] year-old
female who was admitted to the facility on [DATE]. Her diagnoses diagnosis included essential hypertension
(high blood pressure).
Record review of Resident#2's MDS dated [DATE] revealed a BIMS score of 08, indicating Resident #2's
cognitive skills for decision making was moderately impaired.
Record review of Resident #2's physician's order summary report for May 2024 revealed an order dated
5/6/2024 for Metoprolol Tartrate Oral Tablet 25mg give 1 tablet by mouth every 12 hours for Hypertension.
Hold for SBP <110 or DBP< 70 or HR < 60.
Record review of Resident #2's MARs revealed Metoprolol Tartrate Oral Tablet 25mg the medication was
administered on the following date and time:
* 5/07/2024 at 9:00pm when the blood pressure was 83/51, on
*5/09/2024 at 9:00 PM when SBP was 105/67, and on
*5/10/2024 at 9:00 PM when SBP was 105/67.
Further record review of the MARs revealed on 05/09/2024 and 05/10/2024 were given by LVN C.
In an observation and interview on 05/15/2024 at 10 :55 Resident #2 was observed in bed. She was alert
and oriented and could make their needs known. She was clean and well-groomed with no offensive odor.
Resident was able to voice her needs. Interview with Resident #2 revealed she had no problems getting her
medications.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
675233
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
675233
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Care at Golfcrest
6150 S Loop East
Houston, TX 77087
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
In an interview on 5/16/2024 at 10:00am with LVN C, she said she was not the one who gave Resident #2
her 9:00pm medication. She said she usually checked the resident blood pressure before her medication
was administered. She said if her blood pressure was in the parameter that it should be held, she would not
give it. She said she would hold the blood pressure medication. She said she it was difficult to say when the
medication was held and when it was documented as given. She said if medications were not given it
should be documented as not given and the reason why it was not given.
In an interview on 05/15/2024 at 3:00pm the DON said her expectations was the orders were followed and
when the vital signs were within the parameters the medications should not be given. She said she was
going to in-service the staff and supervise the blood pressure medication administration.
In an interview on 5/16/2024 at 3:20pm with LVN B she said she was sure she held the medications
because she knew that Resident #2's blood pressure sometimes ran low. She said she might have
documented incorrectly. She said that if the blood was already low and she gave the medication it would
bring the blood pressure lower, and this would cause the resident to get dizzy and could get sick.
Further interview with the DON on 5/16/2024 at 3:45pm she said Resident #2's blood pressure could drop
when the medication that was to be held was given. That could cause her to become dizzy and fall and
injury could occur. The DON said Resident #2's blood pressure medication has parameters and once the
blood pressure was checked, and the blood pressure was in the parameter if it was ordered to be held, then
they should not have given the medication. She said she was going to in-service the staff regarding blood
pressure parameters, and she was going to audit blood pressure medication to ensure they have
parameters in place, and staff were following the parameters.
In an interview on 5/16/2024 at 4:00pm, the Administrator stated the expectations were that medications
were given according to the physician's orders. He said he would have to ensure that staff were in-serviced.
Record review of the facility policy titled Administering Oral Medication undated read in part . Purpose: To
provide guidelines for safe administration of oral medications. Preparation. Verify that there is a physician's
order for this procedure. Steps in the Procedure . 13. Perform any pre-administration assessment
Medications are prepared, administered, and recorded by the same authorized medical/licensed staff.
Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to
medication administration .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675233
If continuation sheet
Page 2 of 2
