Health inspection·July 17, 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 interview and record review, the facility failed to ensure its residents were free of any significant medication errors for 4 (Resident #1 Resident #2, Resident #3 and Resident #4) of 10 residents reviewed for medications. The facility failed to administer Midodrine (medication to increase blood pressure) per parameters stated in physicians' orders for a total of 10 doses in [DATE] for Resident #1.The facility failed to administer Midodrine per parameters stated in physicians' orders for a total of 11 doses in [DATE] for Resident #1.The facility failed to administer Midodrine per parameters stated in physicians' orders for a total of 1 dose in [DATE] for Resident #2.The facility failed to hold Midodrine per parameters stated in physicians' orders for a total of 5 doses in [DATE] for Resident #3.The facility failed to hold Midodrine per parameters stated in physicians' orders for a total of 3 doses in [DATE] for Resident #3.The facility failed to hold Nifedipine (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 1 dose in [DATE] for Resident #4. The deficient practice placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications. Findings Included: Resident #1Record review of Resident #1's face sheet indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses to include: Parkinson's disease (progressive disorder that affects the nervous system, and the parts of the body controlled by the nerves), low blood pressure, anxiety disorder, dementia (loss of cognitive functioning) and vitamin deficiency. Record review of Resident #1's Quarterly MDS assessment dated [DATE], indicated he had active diagnoses in the last 7 days of orthostatic hypotension (form of low blood pressure that happens when standing after sitting or lying down) and he was moderately impaired cognitively with a BIMS score of 12. He used a manual wheelchair independently for mobility and required setup or clean-up assistance with transfer to and from a bed to wheelchair. Record review of Resident #1's Comprehensive Care Plan last revised [DATE], indicated he had hypotension related to low BP. Goal: resident will be free of s/s of hypotension. Interventions: encourage adequate fluid intake and healthy diet, give medications per orders, and monitor/document/ report prn any s/s causative factors; dehydration, allergic reactions, orthostatic or postural hypotension, trauma, septicemia (bloodstream infection), blood loss, post prandial hypotension (blood pressure drops after you eat a meal).Record review of Resident #1's physicians' orders indicated: check BP every 8 hours and administer midodrine per order as required according to bp result every 8 hours for maintaining healthy bp related to Hypotension, and Midodrine oral tablet 2.5 mg give 1 tablet by mouth every 8 hours as needed for hypotension, give for SBP less than 90 or DBP less than 60 order dated [DATE]. Record review of Resident #1's MAR for [DATE] Blood Pressure monitoring indicated: [DATE] at 10:00 p.m. BP 109/58, [DATE] at 6:00 a.m. BP 120/52, [DATE] at 2:00 p.m. BP 70/40, [DATE] at 6:00 a.m. BP 100/58, [DATE] at 2:00 p.m. BP 98/52, [DATE] at 10:00 p.m. BP 122/56, [DATE] at 10:00 p.m. BP 178/56, [DATE] at 2:00 p.m. BP 80/55, [DATE] at 2:00 p.m. BP 133/55, and [DATE] at Residents Affected - Some Page 1 of 5 675540 675540 07/17/2025 Liberty Health Care Center 1206 N Travis St Liberty, TX 77575

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10:00 p.m. BP 128/59.Record review of Resident #1's MAR for [DATE] indicated Midodrine was not given on: [DATE] at 10:00 p.m. BP 109/58 by LVN B, [DATE] at 6:00 a.m. BP 120/52 by LVN C, [DATE] at 2:00 p.m. BP 70/40 by LVN D, [DATE] at 6:00 a.m. BP 100/58 by LVN E, [DATE] at 2:00 p.m. BP 98/52 by LVN D, [DATE] at 10:00 p.m. BP 122/56 by LVN F, [DATE] at 10:00 p.m. BP 178/56 by LVN B, [DATE] at 2:00 p.m. BP 80/55 by LVN D, [DATE] at 2:00 p.m. BP 133/55 by LVN D, and [DATE] at 10:00 p.m. BP 128/59 by LVN B.Record review of Resident #1's MAR for [DATE] Blood Pressure monitoring indicated: [DATE] at 10:00 p.m. BP 148/47, [DATE] at 2:00 p.m. BP 121/57, [DATE] at 10:00 p.m. BP 131/58, [DATE] at 10:00 p.m. BP 112/46, [DATE] at 2:00 p.m. BP 113/48, [DATE] at 10:00 p.m. BP 100/59, [DATE] at 10:00 p.m. BP 108/57, [DATE] at 2:00 p.m. BP 105/54, [DATE] at 2:00 p.m. BP 147/45, [DATE] at 2:00 p.m. BP 98/53 and [DATE] at 2:00 p.m. BP 75/84.Review of Resident #1's MAR for [DATE] indicated Midodrine was not given on: [DATE] at 10:00 p.m. BP 148/47 by LVN B, [DATE] at 2:00 p.m. BP 121/57 by LVN D, [DATE] at 10:00 p.m. BP 131/58 by LVN E, [DATE] at 10:00 p.m. BP 112/46 by LVN B, [DATE] at 2:00 p.m. BP 113/48 by LVN G, [DATE] at 10:00 p.m. BP 100/59 by LVN B, [DATE] at 10:00 p.m. BP 108/57 by LVN B, [DATE] at 2:00 p.m. BP 105/54 by LVN E, [DATE] at 2:00 p.m. BP 147/45 by RN H, [DATE] at 2:00 p.m. BP 98/53 by LVN E and [DATE] at 2:00 p.m. BP 75/84 by RN H.During an interview on [DATE] at 11:30 a.m., Resident #1 said he received his medications as prescribed, and they monitored his BP routinely. Resident #1 denied any signs and symptoms of low BP (dizziness, light headedness, fainting, blurred vision, and/or increased fatigue) and said if he did have any, he would notify the nursing staff. Resident #1 said he did have a history of falling but it was because he tried to ambulate without assistance. Resident #2Record review of Resident #2's face sheet indicated he was an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: high blood pressure, end stage renal disease (last stage of long-term kidney disease), diabetes, dementia, anxiety and depression. Record review of Resident #2's annual MDS assessment dated [DATE], indicated he had active diagnoses in the last 7 days of hypertension (condition in which the force of the blood against the artery walls is too high) and orthostatic hypotension, and he was cognitively intact with a BIMS score of 15. He used a manual wheelchair for mobility but was totally dependent on staff for mobility and assistance with transfer to and from a bed to wheelchair.Record review of Resident #2's Comprehensive Care Plan last revised [DATE], indicated he had hypertension related to lifestyle choices. Goal: resident will remain free of complications related to hypertension. Interventions: Administer Midodrine if SBP is less than 110 and DBP is less than 60, Give PRN Hydralazine per MD orders if SBP is over 160 or DBP is over 110 and Monitor/record use/side effects of medication. He has hypotension. Goal: resident will remain free from signs and symptoms of hypotension. Interventions: . Educate resident/family/caregivers to change position slowly going from lying, sitting to standing, encourage adequate fluid intake and a healthy diet. and give medications as ordered. Monitor for side effects and effectivenessRecord review of Resident #2's physicians' orders indicated: Midodrine oral tablet 5 mg give 1 tablet by mouth every 12 hours as needed for SBP <100 or DBP <60 related to orthostatic hypotension; order dated [DATE].Record review of Resident #2's MAR for [DATE] indicated on [DATE] at 7:00 p.m. BP reading of 125/54 and Midodrine 5mg 1 tablet was not given by LVN L as needed for SBP <100 or DBP <60 related to orthostatic hypotension.During an interview on [DATE] at 9:00 a.m., Resident #2 said he received his medications as prescribed, and they monitored his BP routinely. Resident #2 denied any signs and symptoms of low BP (dizziness, light headedness, fainting, blurred vision, and/or increased fatigue) and said if he did have any, he would notify the nursing staff. Resident #2 said staff checked his BP frequently because he went out to dialysis, and it caused his BP to drop. He said he was to be administered Midodrine if his BP reading 675540 Page 2 of 5 675540 07/17/2025 Liberty Health Care Center 1206 N Travis St Liberty, TX 77575

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was low but did not recall his BP being low enough for the Midodrine to be administered. Resident #3Record review of Resident #3's face sheet indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses to include: sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), osteomyelitis of vertebra (infection in the vertebrae in the spine), paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body), depression, atrial fibrillation (type of irregular heartbeat) and bed confinement status. Record review of Resident #3's admission MDS assessment dated [DATE], indicated he had active diagnoses in the last 7 days of atrial fibrillation or other dysrhythmias, (abnormal or irregular heartbeats) and he was cognitively intact with a BIMS score of 14. He was bedfast and dependent on staff for mobility.Record review of Resident #3's Comprehensive Care Plan last revised [DATE], indicated he had hypotension. Goal: resident will remain free of complications related to hypotension. Interventions: . Encourage adequate fluid intake and a healthy diet and give medications as ordered. Monitor for side effects and effectiveness.Record review of Resident #3's physicians' orders indicated: Midodrine oral tablet 5 mg give 3 tablets by mouth three times a day for hypotension, hold for systolic BP greater than 120.Record review of Resident #3's MAR for [DATE] Blood Pressure monitoring indicated: [DATE] at 2:00 p.m. BP 130/79, [DATE] at 2:00 p.m. BP 126/74, [DATE] at 2:00 p.m. BP 129/68, [DATE] at 2:00 p.m. BP 122/65, and [DATE] at 2:00 p.m. BP 130/75. Record review of Resident #3's MAR for [DATE] indicated Midodrine was not held on: [DATE] at 2:00 p.m. BP 130/79 by LVN J, [DATE] at 2:00 p.m. BP 126/74 by LVN D, [DATE] at 2:00 p.m. BP 129/68 by LVN J, [DATE] at 2:00 p.m. BP 122/65 by LVN D, and [DATE] at 2:00 p.m. BP 130/75 by LVN J.Record review of Resident #3's MAR for [DATE] Blood Pressure monitoring indicated: [DATE] at 10:00 p.m. BP 128/74, [DATE] at 2:00 p.m. BP 174/94, and [DATE] at 9:00 a.m. BP 157/74.Review of Resident #3's MAR for [DATE] indicated Midodrine was not held on: [DATE] at 10:00 p.m. BP 128/74 by LVN L, [DATE] at 2:00 p.m. BP 174/94 by LVN K, and [DATE] at 9:00 a.m. BP 157/74 by RN H.During an interview on [DATE] at 11:45 a.m., Resident #3 said he received his medications as prescribed, and they monitored his BP routinely. Resident #3 denied any signs and symptoms of low BP (dizziness, light headedness, fainting, blurred vision, and/or increased fatigue) and said if he did have any, he would notify the nursing staff. Resident #4Record review of Resident #4's face sheet indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses to include: high blood pressure, dementia, chronic pain and muscle weakness. Record review of Resident #4's Quarterly MDS assessment dated [DATE], indicated she had active diagnoses in the last 7 days of hypertension, and she was able to make herself-understood and usually understood others. No BIMS score was identified. She used a manual wheelchair independently for mobility and required maximum assistance with transfer to and from a bed to wheelchair.Record review of Resident #4's Comprehensive Care Plan last revised [DATE], indicated she was on medication for hypertension related to lifestyle choices. Goal: resident will remain free of complications related to hypertension. Interventions: . give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. per MD order hold medication if SBP (systolic blood pressure) is less than 110, DBP (diastolic blood pressure) or pulse is less than 60.Record review of Resident #4's physicians' orders indicated: Nifedipine ER Oral Tablet Extended Release 24Hour 60 mg give 1 tablet by mouth one time a day related to hypertension; hold if SBP <110, DBP <60, order dated [DATE].Record review of Resident #4's MAR for [DATE] indicated on [DATE] at 8:00 a.m. Nifedipine ER 60 mg 1 tablet by mouth one time a day related to hypertension; hold if SBP <110, DBP <60 was administered by MA N with a blood pressure reading of 112/50. During an interview on [DATE] at 675540 Page 3 of 5 675540 07/17/2025 Liberty Health Care Center 1206 N Travis St Liberty, TX 77575

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 11:45 a.m., Resident #4 said she received her medications as prescribed, and they monitored her B/P routinely prior to administering BP medication. Resident #4 denied any signs and symptoms of low BP (dizziness, light headedness, fainting, blurred vision, and/or increased fatigue) and said if she did have any, she would notify the nursing staff.Record review of facility incidents for June and [DATE] did not indicate Resident #1, Resident #2, Resident #3, and Resident #4 had falls or incidents related to the medication errors.During an interview on [DATE] at 8:00 a.m., MA N observed checking BP prior to administer BP medications and said she checked resident's BP prior to administering BP medications. She said she checked the BP and then reviewed the resident's MAR to determine if the blood pressure medication was to be administered. She said some residents had parameters to hold the blood pressure medication if the BP was low. She said if the resident's BP was low, she held the medication, documented on the MAR and reported it to the resident's charge nurse. She said that the charge nurses administered medications for hypotension but if she was responsible for administering those, she would do the same process, check the BP, review and administer the medication if within acceptable parameter. She said if residents' blood pressure was low and they were still given a blood pressure medication, it could get too low or if blood pressure was low and medications were not given to increase it, that could cause hypotension symptoms. She said residents were at risk for hypotension including passing out or dizziness which could result in a fall or injury. She said she received training about administering BP medication back in [DATE].During an interview on [DATE] at 11:57 a.m., LVN D said depending on the time, a medication aide or nurse administered the resident's medications. She said the resident's blood pressure should be checked each time the blood pressure medication was due. She said the blood pressure protocol ordered by the physician should be followed. She said if residents' blood pressure was low and they were still given a blood pressure medication, it could get too low or if blood pressure was low and medications were not given to increase it, that could cause hypotension symptoms. She said residents were at risk for hypotension including passing out or dizziness which could result in a fall or injury.During an interview on [DATE] at 2:00 p.m., LVN K said depending on the time, a medication aide or nurse administered the resident's medications. She said the resident's blood pressure should be checked each time the blood pressure medication was due, and orders/MAR reviewed for parameters. She said the blood pressure protocol ordered by the physician should be followed. She said residents were at risk for hypotension symptoms (dizziness, lightheadedness, drowsy, and unresponsiveness) if medications were not administered for hypotension or if hypertension medications were administered when BP was low (out of parameters). During an interview on [DATE] at 2:45 p.m., RN H, said the BP reading of 75/84 was an error, and she did administer Resident #1's Midodrine on [DATE] for low blood pressure. She said she typically looked at the medication and parameters before administering, but she did not remember why she had not looked at the parameters on [DATE] and hold the Midodrine when BP reading was 147/45. RN H said if the blood pressure dropped too low Resident #1 could have had dizziness, passed out, or even possibly died. She stated she had been in-serviced recently regarding blood pressures, parameters and medication administration during her recent orientation. During an interview on [DATE] at 9:00 a.m., LVN L said she checked resident's BP prior to administering BP medications. She said she checked the BP and then reviewed the resident's MAR to determine if the blood pressure medication was to be administered. She said some residents had parameters to hold the blood pressure medication if the BP was low and medications to administer if BP was low. She said she checked the BP, reviewed and administered the medication if within acceptable parameters. She said if residents' blood pressure was low and they were still given a blood pressure medication, it could get too low or if blood pressure was low and medications 675540 Page 4 of 5 675540 07/17/2025 Liberty Health Care Center 1206 N Travis St Liberty, TX 77575

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were not given to increase it, it could cause hypotension symptoms. She said residents were at risk for hypotension including passing out or dizziness which could result in a fall or injury. She said she received training about administering BP medication back in [DATE].During an interview on [DATE] at 9:45 a.m., LVN M, said the LVNs administered Resident #1's BP medications due to his hypotension and staff checked his blood pressure every 8 hours and as needed. She said standard facility protocol was if systolic BP was less than 120 to administer the Midodrine but was unsure what to do if the diastolic BP was low. LVN M said she would probably hold the Midodrine or call the physician for clarification if the systolic BP was above 120 but the diastolic BP was below 60. She said she took the BP prior to medication administration and would review the MAR/orders to clarify parameters if medication was to be administered or held. She said she would contact the physician if she was unsure of the parameters or dosing, or if BP medication was repeatedly being held or missed. LVN M said if the blood pressure dropped too low Resident #1 could have dizziness, unresponsiveness, or even possibly die. She stated she had been in-serviced recently regarding blood pressures, parameters and medication administration during her recent in-service.During an interview on [DATE] at 12:30 p.m., the DON said she expected her nurses and medication aides to follow physicians' orders. She stated she expected them to read the MAR and follow parameters. The DON stated that anytime a resident's blood pressure was high or low she would expect staff to look to see if the resident had any standing PRN orders. She said if a resident's blood pressure was low and the blood pressure medication was administered, it could cause blood pressure to bottom out. She said if a resident's blood pressure was low and medications to increase blood pressure were not administered, it could cause blood pressure to remain low or drop. She said the resident could experience symptoms of hypotension including syncope (fainting or passing out), confusion, and even death. During an interview on [DATE] at 1:15 p.m., the Administrator said she expected her staff to following physicians' orders and to be competent enough to notice a high or low blood pressure and to check the orders for parameters. Record review of a facility's Medication Administration policy dated 2024, indicated Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 675540 Page 5 of 5