Health inspection·June 21, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 2 residents (Resident #1) reviewed for clinical documentation and medical records accuracy. The facility failed when Resident #1's June 2025 MAR order for Midodrine was inaccurately dated, as well as the ADON had never signed the MAR that Resident #1's Midodrine was administered on 06/13/2025. This deficient practice could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in services, or a potential decline in the resident's health. The findings included: Record review of Resident #1's face sheet, dated 06/21/25, revealed a [AGE] year-old male with an original admission date of 08/01/24, and a recent admission date of 05/23/25. Diagnoses included Chronic Pulmonary Edema (a condition characterized by abnormal buildup of fluid in the lungs), Adult Failure to Thrive (a condition that affects appetite, weight, and activity), Peripheral Vascular Disease (a disorder of the blood vessels outside of the heart), End Stage Renal Disease (advanced state of kidney failure that occurs with the gradual loss of kidney function), and Type 2 Diabetes (a condition that affects how the body uses insulin and sugar). Record review of Resident #1's Quarterly MDS assessment, dated 05/21/25, revealed a BIMS score of 10, indicating moderately impaired cognition. Record review of Resident #1's care plan, initiated 08/02/24, revealed Resident #1 was a full code. Record review of Resident #1's care plan, initiated 02/06/25, revealed Resident #1 was resistive to care and resistive to following dietary and fluid restriction orders, as well as refused dialysis treatments at times. Record review of Resident #1's care plan, initiated 08/22/24, revealed Resident #1 had hyperlipidemia related to hypertension, and hypertension related to lifestyle choices. Record review of Resident #1's care plan, initiated 08/22/24, revealed Resident #1 had a potential Page 1 of 2 676125 676125 06/21/2025 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0842 for fluid volume overload related to kidney failure. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's physician orders, started and stopped 06/14/25, revealed an order for Midodrine 10 MG, give 1 tablet by mouth every 8 hours as needed for hypotension if blood pressure was below 100/60. Order was entered by LVN-E. Residents Affected - Few Record review of Resident #1's June 2025 MAR revealed blood pressure on the morning of 06/13/24 was 121/72, so Resident #1's routine hypertension medications were administered, to include Amlodipine, Lisinopril, Clonidine, and Carvedilol. Resident #1's blood pressure on 06/13/25 at 4:00 PM was 82/48, so routine hypertension medications were withheld, to include Carvedilol and Clonidine. This same MAR revealed the order for Midodrine as: Midodrine 10 MG, give 1 tablet by mouth every 8 hours as needed for hypotension if blood pressure was below 100/60, start date 06/14/25, and stop date 06/14/25. The Midodrine signature box was left blank. In an interview with the ADON on 6/21/25 at 8:51 AM, she stated she was here on 6/13/25 when Resident #1 came back from dialysis and started having low blood pressure issues. She stated Resident #1 was doing okay other than he looked pale and tired. She stated she tried to get Resident #1 to lay down, but he refused. She stated Resident #1 was not complaining about anything, but when the nurse on the floor checked his blood pressure, it was really low. She stated she was trying to help the new nurse out, so she was the one who called the doctor and got the order for the Midodrine, and she administered the Midodrine to Resident #1. She stated she should have put the order in herself instead of letting the new nurse put the order in for her, since she was the one who obtained the order. The ADON also stated she was the one who should have signed the MAR since she was the one who administered the Midodrine to Resident #1. In an interview with the DON on 06/21/25 at 9:57 AM, she stated the order for Midodrine was obtained from the physician by the ADON on 06/13/25, and the ADON should have put the order in, but LVN-E, who was the nurse on the floor that evening, ended up putting the order for the Midodrine in the system for the ADON. She stated he was still new and learning, so when he put the order in the system he should have clicked the start now box, but because he did not, the order did not show to start until the next day, which was why it was transcribed wrong in the MAR. She stated the ADON was the one who should have signed the MAR since she was the one who gave the Midodrine. In an interview with LVN-E on 6/21/25 at 11:22 AM, LVN-E stated Resident #1 got the Midodrine on his shift, and he was stable throughout the night. He stated the ADON gave the Midodrine to Resident #1, but he entered the order. He stated he may have entered the order wrong because the order was obtained, and the medication was given on 06/13/25 not 06/14/25. He stated the ADON was busy trying to help him, and her shift was over, and she was trying to leave, so he put the order in for her. He also stated he was unsure why the MAR was never signed. Record review of the facility's Medication Policy, implemented 10/24/22, revealed 10. Review MAR to identify medication to be administered. 17. Sign MAR after administered. Record review of the facility's Documentation Policy, implemented 10/24/22, revealed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 676125 Page 2 of 2