Health inspection·August 29, 2024

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater when the facility had a medication error rate of 29% based on 9 errors of 31 opportunities, which involved 2 of 4 residents (Resident #67 and # 56) observed during medication administration. Residents Affected - Some -The facility failed to ensure Resident #67's extended release (ER) medications were not crushed. - LVN A failed to follow physician orders for water flushes after medication administration given via the G-Tube (a tube into the stomach that delivers formula for nutrition and medication) for Resident #56. - LVN A failed to follow facility policy by crushing all medications (tablets) together during observation on medication administration on Resident #56. - LVN A failed to follow physician order for checking Resident #56's residual and placement before medication administration through the G-tube. These failures could place residents at risk of unwanted side effects and not receiving therapeutic dosage of medications. Findings include: 1.Review of Resident #67's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, major depressive disorder, hypertension, obesity, dysphagia (difficult with swallowing) and asthma. Review of Resident #67's Quarterly MDS assessment, dated 07/12/24, reflected a BIMS score of 12 indicating resident had mild cognitive impairment. Resident #67 required minimal assistance with activities of daily living. Review of Resident #67's physician orders reflected the order for Potassium Chloride ER Tablet Extended Release 20MEQ Give 1 tablet by mouth one time a day for low Potassium, order date 05/13/24, and Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 30 MG (Isosorbide Mononitrate) Give 1 tablet by mouth one time a day for chest pain, order date 09/16/23. (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 5 Event ID: 675820 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 675820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lennwood Nursing and Rehabilitation 8017 W Virginia Dr Dallas, TX 75237 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)