Health inspection·November 20, 2023

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 residents were free of any significant medication errors for one of 6 (Resident #1) residents reviewed for medication administration. Residents Affected - Few -Resident #1 received Propranolol HCl oral tablet 20mg, over the course of 8 days, without an order. This failure could place residents who receive blood pressure medications at an increased risk for complications such as decreased blood pressure, decrease pulse, and an exacerbation of symptoms and disease process. Findings include: Record review of Resident #1's face sheet revealed an [AGE] year-old female re-admitted on [DATE] with diagnoses that included, but were not limited to, hypertensive urgency, essential hypertension, essential tremor, depression, anxiety disorder, muscle weakness and atrophy, not elsewhere classified, fibromyalgia, cognitive communication deficit, pain, unspecified fall, subsequent encounter, syncope and collapse, acute kidney failure. Record review of Resident #1's current MDS completed on 11/17/2023 revealed, in part, that her speech was clear, she was understood and understood others. She had a BIMS score of 15 out of 15, which indicated her cognition was intact. She was independent with partial/moderate assistance with some of her activities of daily living. She was occasionally incontinent of bladder and always continent of bowl. Record review of Resident #1's care plan, dated 11/08/2023, revealed, in part: Focus [Resident #1] has hypertension, date initiated 11/16/2023. Intervention .Evaluate blood pressure, date initiated 11/16/2023. Record review of Resident #1's admission orders, dated 11/03/2023, revealed, in part, that Resident #1 started Propranolol 20mg tablets, with a start date of 09/26/2023. Resident #1 stated that she was placed on the Propranolol for essential tremor, Resident #1 did not like how the medication made (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: 675904 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 675904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106 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)