Brookshire Residence And Rehabilitation Center

F-F755

Resident was administered 100mg of Midodrine instead of the verbally ordered amount of 10mg.

Resident assessed by LVN and sent to ER for evaluation. (returned 2/11/2025)

Family called

MD/NP notified.

Audit all Midodrine orders by DON 2/10/2025

Resident #1 medication clarified/fixed 2/10/2025 (ultimately discontinued upon hospital return)

Notify Medical Director 2/10/2025 11:03am brief QAPI discussion to establish plan (this)

New orders will be reviewed by DON/designee daily to ensure accurately transcribed and that the computerized order matches the medication card. Results of these audits will be discussed in morning meeting and any discrepancies will be rectified immediately.

LVN disciplinary action and 1:1 education 2/10/2025 related to transcription and medication administration to ensure the computerized order matches the medication card.

MA disciplinary action and 1:1 education 2/10/2025 related to medication administration to ensure the computerized order matches the medication card.

MA removed from MA role as of 2/10/2025 until further education and training occurs and she successfully completes 3 competency checks by DON.

Facility MAs and nurses re-educated on medication administration started 2/10/2025 by the DON. Education was completed on 2/11/2025 and staff not allowed to work without training completion. The education consisted of right person, right time, right dosage, right route, right drug. Also included matching computerized order to medication card.

Nurses and MAs were provided education and post-test for Midodrine administration specifically by the DON

on 2/10/2025 and no one can return to work unless education has been completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 675700 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675700 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423

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 Nurses re-educated on transcription of orders/meds started 2/10/2025 by the DON. Education was completed on 2/11/2025 and staff not allowed to work without training completion. This education consisted Level of Harm - Immediate of rights as well as repeating back to prescriber for accuracy. jeopardy to resident health or safety Notified Pharmacy Consultant by DON 2/11/2025 and will review all active residents' entire medication regimen monthly and provide verbal and written reports for verification. Next visit scheduled for week of Residents Affected - Few 2/17/2025.

Abuse, Neglect & Exploitation re-education started 2/11/2025 by the DON for all active staff members to include types, coordinator, and notification. This was completed on 2/11/2025 and staff may not return to work until the education is completed.

Full Ad hoc QAPI 2/11/2025 with Medical Director present

DON audit all new orders from 2/1-2/11/2025 on 2/11/2025 with no inaccuracies found.

DON/designee to complete 100% audit of all medications for all current residents completed 2/13/2025 with no discrepancies identified.

Policies Reviewed with no changes required: Abuse, Neglect and Exploitation, Medication Administration, Medication Orders, Medication Regimen Review.

Monitoring for implementation of the POR was conducted on 2/14/2025:

In a telephone interview on 2/14/2025 at 10:30 am MA D stated that she was in serviced on 2/10/2025. She stated that she was in serviced on 10 Rights of Drug Administration to include right drug, right patient, and right dosage. She stated that was in serviced on passing medication to include making certain the MAR and

the blister packs match. She stated if the MAR and the blister pack does not match, she must report it to the nurse. She stated that she was in serviced on Midodrine to include what the medication is for and the parameters.

In an interview on 2/14/2025 at 2:42 pm Nurse F stated she received an in -service on 2/10/2025 regarding 10 Rights of Drug Administration, Midodrine, Medication Administration and Medication Transcribe. She stated that 10 rights of drug administration include right medication, right patient, right time, right dosage, and right documentation. She stated that when taking orders from NP or physician she must repeat the order back to the NP/physician. She stated that if there any discrepancies with the residents orders she must contact the NP or physician.

In an interview on 2/14/2025 at 3:15 pm with Nurse G he stated he was in serviced on 2/10/2025. He stated

he was in serviced on Medication transcription, 10 rights of drug administration, medication administration and Midodrine. He stated that Midodrine is a medication used mainly with residents who have hypotension, and this medication is used to raise blood pressure. He stated that the normal dosage 1 tablet and 5-10 mg.

He stated that this medication is administered based on the parameters. He stated the rights of drug administration include right medication, right patient, right medication, right dosage, right [NAME], right time, right documentation, history, assessment and evaluation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 675700 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675700 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423

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 In an interview on 2/14/2025 at 3:27 pm with ADON B she stated she in serviced the Nurses and MA's on 2/10/2025. She stated that the in-services were 10 Rights of Drug Administration and Midodrine. She stated Level of Harm - Immediate that staff were in serviced to follow upon each medication. If there is a discrepancy between the blister pack jeopardy to resident health or and the MAR staff should notify the nurse manager immediately prior to administering the medication. She safety stated that she in serviced the Nurses and CMAs on the medication Midodrine. Staff was in-serviced that Midodrine is used to treat low pressure and each Midodrine should have parameters. She stated she was in Residents Affected - Few serviced on medication transcription and administration.

In a telephone interview on 2/14/2025 at 3:45 p.m., Nurse A she stated she was in serviced on 2/12/2025.

She stated that she was in serviced on the medication Midodrine, 10 Rights of Drug Administrations, and Medication Administration. She stated that the in services covered transcribing to include repeating the orders back to the NP or physician. She stated that if there is a medication the on-call physician should be contacted immediately. She stated that she was in services on the 10 rights of medication to include right patient, right medication, right dose, right route, right documentation, and right time.

In an interview on 2/14/2025 at 3:50 pm, Nurse H stated in serviced on 2/10/2025. She stated that she was

in serviced on 10 Rights of Drug Administration, Midodrine, Medication Administration and Transcribe. Nurse H stated that the resident has the right to dignity, the right to refuse, the right to grievances. She stated that Midodrine is used to treat hypotension and when a resident is taking Midodrine there are parameters specific to that resident as ordered by the NP or physician. Nurse H stated that the adverse consequences of the medication Midodrine are high blood pressure, dizziness which could lead to elevated blood pressure and stroke. She stated that the 10 rights of medication-right patient, right medication, right dose, right route, right time and right documentation. She stated that when taking orders from the NP or physician the order must be read back to the NP or physician for accuracy.

In an interview on 2/14/2025 at 4:10 pm, Nurse I stated she was in serviced on 2/10/2025. She stated that

she was in serviced on Midodrine. She stated that Midodrine is used for low blood pressure. She stated that if a resident is given to much resident the adverse consequences could be heart failure. She stated that she

in serviced on medication transcribing to include check order and make certain it the orders has the correct date, time, route and repeat the orders back to the physician. She stated she was in serviced on the 10 Right of Drug Administration to include right medication, right patient, right route, right time, and right to refuse.

She stated that if a medication is given error the supervisor and NP need to be contacted immediately.

In an interview on 2/14/2025 at 4:30 p.m., Nurse B stated she was in serviced on 2/10/2025. She stated that

she was in serviced on Midodrine. She stated the order on the MAR must match the blister pack. She stated that Midodrine has parameters, and this must be notated on the MAR and the blister pack. She stated that when verbally receiving orders from the NP or physician she must repeat the order back for accuracy. She stated that was in serviced on Midodrine. She stated that Midodrine is given to residents who have low blood pressure. She stated that this medication must be administered according to the NP or physician's order.

She stated that was in serviced on the 10 Rights of Drug Administration. Nurse B stated both in services were completed on 2/14/2025.

In an interview on 2/14/2025 at 4:45 p.m., Resident # 1 stated she was well and she did not have any concerns. She stated did not know anything about her medication. She stated that staff administers the medication, and she could not remember anything else pertaining to her medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 675700 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675700 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423

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 Record review of the facility's Pharmscript policy dated (8/2020) revealed read in part .The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. In Level of Harm - Immediate collaboration with facility staff, the consultant pharmacist helps to identify communicate, address and resolve jeopardy to resident health or concerns and issues related to the provision of pharmaceutical services. This includes, but not limited to:5 d) safety Assisting in the identification and evaluation of medication-related issues, including the prevention and reporting of medication errors and the provisions of and monitoring of the use of medication-related devices, Residents Affected - Few 6a) reviewing the medication regiment of each resident at least monthly or [NAME] frequently under certain conditions, incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review, and documenting the review findings

in the resident's medical record or in a steadily retrievable format if utilizing electronic documentation, 6g) reviewing medication administration records (MARs), treatment administration records (TARs) and physician orders to ensure proper documentation of medications orders and administration of medications to residents.

Record review of the facility's Medication Regimen Review Verification (MRR) dated January 2025 revealed

on 1/9/2025 the pharmacist consultant reviewed Resident # 1 MRR and documented Medication Regimen

Review has been performed and any inappropriate findings were communicated to the Physician and Director of Nursing through the utilization of the Pharmaceutical Consultant Report. The current prescription therapy is considered appropriate at this time and any indicators concerning the Interpretive Guidelines will be addressed when clinical conditions warrant such attention.

Record review of the facility's Nursing Policies and Procedures dated (revised 6/2019) revealed read in part

The facility's nursing and pharmacy services will assess, monitor and evaluate the effectiveness of the therapeutic medication regimen including all drugs ( prescription and non-prescription) in order to enhance

the resident's quality of life; 3) the authorized licensed or certified/permitted medication aide or by state regulatory or guidelines staff members follow the MAR prepared for the patient/resident/by identifying: a)right resident, b)right drug, c)right dose, d)right time, e) right route, f)right charting, g)right results and h) right reason, 4) The authorized licensed or certified /permitted medication aide or by state regulatory guidelines staff member identifies, that the following information, but not limited to, id documented on the MAR: a)correct physician's order, b)medication and label are correct, and c) label and physician's order are correct; 5) The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member reads the label on the medication three (3) times: a)before removing the medication from the drawer, b) before pouring the medication and c)after pouring the medication;6) The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member seeks assistance from the nursing supervisor/designee and consulting pharmacist when any aspect of medication administration is in question.

Record review confirmed the medication carts were audited as noted on the POR.

Record review confirmed all Midodrine orders were audited as noted on the POR.

Record review an [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 675700