Health inspection·April 16, 2025

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 the medication error rate was not 5 percent or greater. The facility had a medication error rate of 6% based on 2 errors for 31 opportunities. The errors effected 1 resident (Resident #8) of 4 residents reviewed for medication administration. Residents Affected - Few -Two medications (Lactobacillus and D-Mannose Oral Capsule 500 mg) for Resident #8 were not dispensed or administered. The failure placed resident at risk for inadequate therapeutic outcomes and a decline in health. Findings included: Record review of Resident #8's admission Record dated 04/15/25 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, mood disorder, hypertension (high blood pressure), presence of cardiac pacemaker, congestive heart failure (CHF) and history of urinary tract infection (UTI). Observation and interview on 04/14/25 at 8:00 a.m. revealed MA A at that medication cart outside of Resident #8's room. MA A looked at the April MAR and retrieved the following medications from the medication cart and dispensed them into a plastic medication cup: 1 tablet of Cranberry (supplement) 1 capsule of Depakote 125 mg (to treat mood disorder) 1 tablet of Folic Acid 1 mg (vitamin) 1 tablet of Lasix 20 mg (to treat CHF) 1 tablet of Nitrofurantoin100 mg (antibiotic to treat UTI) 2 tablets of Acetaminophen 500 mg (to treat pain) 1 tablet of Venlafaxine HCl 100 (to treat depression) Continued observation revealed MA A closed the medication cart and lock it. The Surveyor asked MA A to count the number of tablets/capsules in the medication cup. MA A counted, then answered Eight. MA A entered the room and obtained Resident #6's blood pressure. The blood pressure cuff display Page 1 of 2 676040 676040 04/16/2025 Paradigm at the Prairies 106 Del Norte Dr El Campo, TX 77437

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed Resident #8's blood pressure was 113/68 mmHg and her heart rate was 70 bpm. MA A dispensed one tablet of Metoprolol 50 mg (for blood pressure) into the cup, making the total 9. MA A administered the 9 tablets/capsules to Resident #8. Record review of the Physician Order dated 02/15/24 for Resident #8 read, in part, .Lactobacillus oral tablet. Give 1 tablet by mouth one time a day related to Urinary Tract Infection site not specified (N39.0) while on antibiotics. Record review of the April 2025 MAR for Resident #8 revealed the Lactobacillus was listed on the MAR as current. The Lactobacillus had not been administered on 04/14/25. Record review of the Physician Order dated 02/03/24 for Resident #8 read, in part, .D-Mannose Oral Capsule 500 mg (D-Mannose) Give 2 capsule by mouth one time a day related to other Urogenital Candidiasis [fungal infection]. Record review of the April 2025 MAR for Resident #8 revealed the D-Mannose was listed on the MAR as current. The D-Mannose had not been administered on 04/14/25. Observation and interview on 04/15/25 12:40 p.m., revealed MA A searched Resident #8's April 2025 MAR. She verbalized the Lactobacillus and the D-Mannose were active orders. She said they were in the refrigerator and had not been administered to Resident #6 on 04/14/25. She said, I did not take it out [of the refrigerator]. In an interview on 04/16/25 at 1:40 p.m., the DON said the process for administering medications was to identify the resident, then make sure which medications were to be administered by looking at the MAR. Next would be to compare it with the medication card, then dispense the right quantity. She said the nurse or MA should key the entry as they read it and dispensed it into the cup. She said after they keyed it, the screen would turn a different color. She stated they should key each one as they go singularly. The DON said Had she [the MA] gone in order and checked it as she went thru them,. she would have seen she missed the two meds. She said the negative outcomes could be missing medications could cause health issues. She said A lot could happen. Record review of the facility policy Medication Administration and Management (revised June 2019) read, in part, .Step III: Administering the Medication Pass 3. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member follows the MAR prepared for the patient/resident by identifying the: A. The Right Patient/Resident B. The Right Drug. C. The Right Dose. D. The Right Time. E The Right Route. F. The Right Charting. G. The Right Results. H. The Right Reason. 676040 Page 2 of 2