F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to provide pharmaceutical services (including
procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each
resident for 1 of 2 residents (Resident #1) reviewed for pharmacy services.
MA K attempted to administer Resident #23's Hydrochlorothiazide (used to treat high blood pressure and
fluid retention) to Resident #1 instead of Hydralazine (used to lower blood pressure and improve blood flow)
as ordered by the MD.
This failure could place residents at risk of medication errors resulting in exacerbation or deterioration in
health conditions.
Findings include:
Record review of Resident #1's face sheet revealed a [AGE] year-old female who readmitted to the facility
on [DATE]. Her diagnoses included hyperkalemia (high potassium), hypertension (high blood pressure),
and pulmonary heart disease.
Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out
of 15 which indicated moderate cognitive impairment. She required assistance from staff with ADL care.
Record review of Resident #1's care plan edited 2/7/25 revealed she was at risk for signs and symptoms of
hyper/hypotension related to diagnosis of hypertension. Nifedipine (medication used to treat high blood
pressure and angina), carvedilol (medication used to treat heart failure, hypertension, and heart attack) as
ordered. The approach was to administer medications as ordered.
Record review of Resident #1's Physician Orders for February 2025 revealed an order for Hydralazine 25
mg give 75 mg every 6 hours, order date 11/9/24.
Record review of Resident #1's MAR dated 1/26/25 - 2/8/25 revealed Hydralazine 25 mg give 3 tablets for
hypertension was scheduled 4 times a day at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m.
In an interview on 2/8/25 at 2:29 p.m., Resident #1 said she received Hydralazine every 6 hours but did not
receive the medication on some shifts.
In an observation and interview on 2/8/25 at 5:02 p.m., MA K began medication administration for
(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:
676362
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
676362
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bridgecrest Rehabilitation Suites
14100 Karissa Court
Houston, TX 77049
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Resident #1. She retrieved Resident #23's Hydrochlorothiazide 25 mg from the cart and placed 3 tablets in
the medication cup. MA K locked the medication cart and entered Resident #1's room. This Surveyor
intervened and asked MA K to return to the medication cart to verify the medication. Observation revealed
the medication in the cup (Resident #23's Hydrochlorothiazide) did not match the medication in Resident
#1's blister pack (Hydralazine). MA K said she could not read the imprint on the tablet and said she may
have grabbed the wrong blister pack. She said the blister pack was in the wrong spot and the medication
she prepared for Resident #1 belonged to Resident #23. She destroyed Resident #23's Hydrochlorothiazide
and prepared Hydralazine 25 mg 3 tablets and administered it to Resident #1.
In an interview on 2/8/25 at 5:19 p.m., MA K said she checked the MAR and blister pack to verify the
correct amount, dosage, and time. She said she reviewed the medication name and the dosage and
thought it matched. She said she noticed it was a different medication when the Surveyor said something.
She said she must have placed Resident #23's medication in Resident #1's spot on the medication cart.
She said Hydralazine was for Resident #1's blood pressure.
In an interview on 2/8/25 at 5:24 p.m., the DON said nursing staff should follow the rights of medication
administration which included verifying the right patient and to compare the MAR to what was on hand. She
said (Hydralazine) was a blood pressure medication and (Hydrochlorothiazide) was a diuretic (used to
increase urine production and help lower blood pressure and fluid retention). She said the risk included
medication error, and it could be detrimental.
Record review of the facility's Medication Management policy dated 4/7/24 read in part, .The staff and
practitioners shall strive to minimize potential for medication error by: A. Following the :8 Rights for
administering medication: 1. The right patient/resident, 2. The right drug .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676362
If continuation sheet
Page 2 of 2
