Health inspection·November 26, 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 Observations, interviews and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 1 resident (Resident #1), reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors when MA B administered Tegretol 200mg (prescribed for seizures, bipolar disorder, and nerve pain), Lipitor 40mg (prescribed to lower cholesterol), Baclofen10mg (muscle relaxer), Metoprolol 25mg (prescribed to lower blood pressure), Neurontin 300mg (prescribed for seizures and nerve pain), Quetiapine Fumarate 200mg (medication prescribed for bipolar disorder and schizophrenia) to Resident #1 on 10/13/25, when these medications were prescribed to another resident. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician.Findings Included: Record review of Resident #1's undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease with early onset (loss of cognitive functioning), essential hypertension (high blood pressure), cognitive communication deficit (inability to communicate clearly), Intermittent Explosive Disorder (mental health condition characterized by sudden, intense episodes of anger or aggression), psychotic disorder with hallucinations due to known physiological condition (mental health disorder), dry eye syndrome of bilateral lacrimal glands (dry eyes), acute atopic conjunctivitis, right eye (infection in the eye), and muscle weakness . Record review of Resident #1's annual MDS, dated [DATE] revealed a BIMS score of 99, which indicated the resident's cognitive status could not be determined using the BIMS assessment. Record review of Resident #1's physician orders dated 10/16/25, did not reveal orders for Tegretol 200mg, Lipitor 40mg, Baclofen10mg, Metoprolol 25mg, Neurontin 300mg, Quetiapine Fumarate 200mg. Record review of physician orders did not reveal any new orders regarding the medication error. Record review of Resident #1's Medication Administration Record, dated 10/01/25-10/31/25, did not reveal physician ordered medications for Tegretol 200mg, Lipitor 40mg, Baclofen10mg, Metoprolol 25mg, Neurontin 300mg, Quetiapine Fumarate 200mg. Record review of Resident #1's Medication Error Report, dated 10/13/25, revealed Resident #1 was given the wrong medication on 10/13/25 at 15:20 (3:30 PM). Record review of Progress notes dated 10/13/25, revealed in part, on 10/13/25 the ADON noted she was advised by MA B that he had given Resident #1 the wrong medications at 15:20 (3:30PM). Record review of Progress notes dated 10/13/25, revealed in part, on 10/13/25 the LVN A noted she was instructed to contact emergency medical services to have Resident #1 transferred to the local hospital at 21:45 (9:45PM). Record review of hospital records, dated 10/14/25, revealed Resident #1 was admitted into the hospital for close monitoring. During an interview on 10/16/25 at 09:30 AM, the ADM said MA B gave Resident #1 the wrong medications. The ADM said the MD was notified and instructed staff to monitor the resident but later instructed staff to send Resident #1 to the hospital. The ADM said Resident #1's vitals were stable when EMS arrived, however Resident #1 was transferred to the hospital as per physician orders. The Residents Affected - Few Page 1 of 4 675407 675407 11/26/2025 Ralls Nursing Home 1111 Avenue P Ralls, TX 79357

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ADM said Resident #1 returned to the facility on [DATE] with no additional orders. During an observation and interview on 10/16/25 at 11:40 AM, Resident #1 was observed rolling up and down the facility hallways holding a shirt. She said she was doing good. She said she needed a shirt for work and then she rolled away. Resident #1 was active and alert. During an observation and interview on 10/16/25 at 2:48 PM, Resident #1 was observed at the nurse station talking with staff. During an interview on 10/16/25 at 3:45 PM, MA B said Resident #1 was having behaviors and hollering in the dining room when he was passing out medications. He said he was parked with the medication cart in front in the nurses station when the ADON brought Resident #1 by the nurse station. MA B said he became irritated as he had verbalized before that he did not like when they set the residents around him when he prepared medications because it caused him to become distracted. He said he mistakenly gave Resident #1 the wrong medications. He immediately realized the mistake and reported it to the ADON and the DON. During an interview on 10/16/25 at 4:26 PM, the ADON said she was in the medication room when she heard Resident #1 hollering. She said Resident #1 indicated she wanted to be moved to the area by where the medication cart was by pointing her finger in that direction when she parked her there, then she went back to the office to continue working. She said MA B was at the medication cart passing out medications. She said MA B told her he gave Resident #1 the wrong medication. She said the MD instructed staff to monitor Resident #1. She said she had received training on and in-services on medications pass. She said staff were provided in-services and completed competency checklists after the incident. The ADON said she did not know what system was implemented to prevent medications errors from happening. She said the MA and nurses were responsible to ensure the medications were given to residents. She said she expected staff do what they knew they were supposed to do, check blood pressures if required, and notify the nurse of any issues. She said MAs went to school and should know how to pass out medications correctly. She said a potential negative outcome of taking the wrong medication was that a resident could end up in the hospital or could experience anaphylaxis- a severe, immediate, potential fatal systemic allergic reaction. During an interview on 10/16/25 at 5:06 PM, the MD said he was notified of the medication error and instructed staff to observe the resident, check vitals, and to send her to the hospital if she was lethargic. He said her vitals were stable and they were monitoring for changes but he then sent her to the hospital for closer observation. He said staff followed the facility protocol. He said an error was an error and the significance of an error did not matter and that he expected staff to follow the medication error protocol. He said errors happened all the time. He said an adverse outcome of an error of one dose was lower. He said a potential negative outcome was the resident could get sleepy, they could have an allergic reaction, or they could die. He said the important thing was to determine how it happened, check the patient, and to do what you could to tend to the patient. During an observation and interview on 10/16/25 at 5:22 PM, Resident #1 was observed rolling down the hallways. She said she was sick in the hospital. She said she was better. During an observation and interview on 10/17/25 at 10:05 AM, Resident #1 was observed in her bedroom dressed as she went through clothes in her dresser. She said she was at the hospital but could not verbalize the reason. During an interview on 10/17/25 at 10:50 AM, the DON said the policy for medication errors was to suspend staff, complete an investigation, complete the medication error form, monitor the resident, and to ensure all medications were given correctly to other residents. She said she became aware of the medication error after the incident occurred via text message from staff. She said the resident's allergies were verified. She said the MD ordered continued monitoring but later ordered staff to contact EMS to transport Resident #1 to the hospital. She said the system in place to prevent medication errors was to re-educate staff and provide them with 675407 Page 2 of 4 675407 11/26/2025 Ralls Nursing Home 1111 Avenue P Ralls, TX 79357

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in-services on medication pass. She said the nurse on duty was responsible to ensure medications were given to residents correctly. She said she expected staff to follow the six rights of residents which were to ensure the dose, person, route, medication, time and documentation were all correct and to make sure they were passing medications correctly. She said she could not speculate what could happen if a person received the wrong medication, they must call the doctor, inform him, take vital signs, follow his orders, and provide close supervision to the resident. During an interview on 10/17/25 at 11:27 AM, the ADM said the policy for when a medication error occurred was to complete notifications and all were done. He said staff completed competencies and were in-serviced on medication pass afterwards. He said he was notified of the medication error immediately after it occurred and the MD ordered staff to monitor the resident. He said staff continued to monitor Resident #1 until the MD ordered the resident to be transferred to the hospital for monitoring. He said the resident was admitted to the hospital for observations and monitoring for 48 hours. He said there had been no issues since she returned to the facility and she was discharged with no new orders. He said the system the facility had in place to prevent medication errors was to provide in-services to staff, educate them, and review competencies. The ADM said the previous DON and ADM provided staff with in-services on medication pass in August 2025. He said the DON and nurse on shift were responsible to ensure medications were passed out correctly, and ultimately he was responsible as well. He said he expected staff to follow the six medication rights when passing out medications, which were the to ensure the dose, person, route, medication, time, and documentation were all correct. He said he could not speculate potential negative outcomes to residents when taking the wrong medications as it was determined on a case-by-case basis, and the outcome could be serious or not be serious. Record review of facility policy titled, Administering Medications, revised in April 2019, revealed in part: Policy StatementMedications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation3. Medications must be administered in accordance with the orders, including any required time frame.6. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include:a. Checking identification band;b. Checking photograph attached to medical record; andc. If necessary, verifying resident identification with other facility personnel.7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Record review of facility policy titled, Medication Errors and Drug Reactions, undated, revealed in part: Purpose: Establish uniform guidelines for reporting and recording of medications errors and drug reactions. Definitions:Medication Error means the observed or identified preparation or administration of medications or biologicals which is not In accordance with:1. The prescriber's order;2. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological or3. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils. Significant medication error means one which causes the resident discomfort or jeopardizes his or her health and safety. Criteria for judging significant medication errors as well as examples are provided below. Significance may be subjective or relative depending on the individual situation and duration, e.g., constipation that Is unrelieved because an ordered laxative is omitted for one day, resulting in a medication error, may cause a resident slight discomfort or perhaps no discomfort at all. However, If this omission leads to constipation that 675407 Page 3 of 4 675407 11/26/2025 Ralls Nursing Home 1111 Avenue P Ralls, TX 79357

F 0760 persists for greater than three days, the medication error may be deemed significant since constipation that causes an obstruction or fecal impaction can directly jeopardize the resident's health and safety. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675407 Page 4 of 4