Austin Oasis, The

medication.

The failure affects one (R1) of three residents reviewed for medication in a total sample

to chronic obstructive pulmonary disorder, bipolar disorder, hypertension, major depressive disorder, and reflux. R1's BIMS (Brief Interview for Mental Status) notes R1 is alert.R1's POS (Physician Order Statement) dated 1/13/2026, notes R1 is supposed to take one Amlodipine Besylate Oral Tablet, 5 mg by mouth in the morning for hypertension. On 11/09/2025, R1 started Lisinopril Oral Tablet, 5 mg, one tablet, in the morning for hypertension.On 2/20/2026, at 5:29 PM, R1 stated, I have two blood pressure medications that I am on. On 2/16/2026, the facility did not have my blood pressure medication, so I did not get it.

The nurse was V4 (Nurse). On 2/20/2026, at 6:33 PM, V4 stated, one of her blood pressure medications was not available. I reordered it for R1. On the February MAR (Medication Administration Record) I must have documented that I gave it by error. I did not contact the physician. I instructed R1 to stay hydrated and to not do too much to elevate her blood pressure.

Honestly, I did not check the convenience box. I was not informed of the procedure on what to do when medication is out. I just knew how to reorder it. I was passing out medications all day and I could not follow up, to be honest. It was just one of them, not both and I cannot remember which one.On 2/20/2026, at 6:45 PM, V2 (DON-Director of Nursing) stated, if the medication is out, the nurse needs to go to the electronic medicine machine or the emergency medication cart and retrieve the medication from there.

The nurse should also call the physician and tell them that the resident did not receive the medication. I was not aware of any incident where a resident did not get their blood pressure medication.

There is an in-service sheet on medication administration.On 2/20/2026, R1's MAR (Medication Administrator Record) from February 2026 was reviewed on 2/16/2026. V4 marked that R1 had received the medication.On 2/20/2026, the facility provided medication administration in-services. V4's name was listed on the in-service form. V4 was in-serviced on medication administration.Facility policy titled, Medication Administration Policy, undated, notes medications should always be prepared, administered, and recorded by the same licensed nurse.

Medications must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time.If a medication and/or treatment error occurs, the licensed nurse will: a.

Immediately notify the attending physician, b.

Describe the error and the resident's response in the Nurse's notes, c.

Complete an Incident Report, d.

Identify the error on the 24-Hour Report, and e.

Monitor the residents' status.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE