Health inspection·August 8, 2024

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 observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for 1 (Resident #8) of 6 residents reviewed for medication errors. Residents Affected - Few -LVN A attempted to administer the wrong dose of insulin to Resident #8 before Surveyor intervention. This failure placed resident at risk for inadequate therapeutic outcomes and decline in health. Findings included: Record review of Resident #8's face sheet revealed an [AGE] year-old female admitted on [DATE]. Her diagnoses included: Type 2 diabetes mellitus with diabetic chronic kidney disease. Record review of Resident #8's annual MDS assessment dated [DATE] revealed a BIMS score of 08 indicating moderate cognitive impairment. Record review of Resident #8's care plan revised on 5/2/2019 read in part, . (Resident #8) is at risk for unstable glucose level r/t dm2 . Interventions/Tasks . Diabetes medication as ordered by doctor . Record review of Resident #8's Order Summary Report dated August 8, 2024, read in part, Novolin R Solution 100 unit/ml (insulin aspart) inject as per sliding scale: if 150 - 199 = 4 units; 200 - 249 = 6 units; 250 - 299 = 9 units; 300 - 349 = 9 units; 350 - 999 = 15 units; IF BS above 349 give 15 UNITS AND CALL MD subcutaneously before meals related to type 2 diabetes mellitus with unspecified complications . order date, 8/31/2021 . Record review of Resident #8's MAR dated August 2024 revealed a blood sugar level of 249 on 08/07/24 at 4:30 p.m. Observation and Interview on 08/07/24 at 4:40 p.m. with LVN A, the Surveyor observed LVN A draw 9 units insulin from multidose vial. LVN A said that Resident #8's blood sugar was 249 and she was to receive 9 units of Novolog according to the sliding scale order. Observed her turn towards the resident to administer the insulin. Surveyor intervened and asked the nurse to check the MAR/Order. LVN A said that the amount of insulin in the syringe was more than prescribed by the doctor. LVN A discarded the additional 3 units of insulin that were prepared after surveyor intervention. LVN A administered 6 units into resident's right upper arm. (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 3 Event ID: 676396 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 676396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE S.P.J.S.T. Rest Home 3 248 Wisteria Lane El Campo, TX 77437 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)