Health inspection·November 25, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs for 1 of 7 residents (Resident #1) reviewed for care plans.The facility failed to implement Resident #1's comprehensive person-centered care plan on 11/11/2025, for medication administration. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs.The findings included: Record review of Resident #1's face sheet dated 11/20/2025 revealed an [AGE] year-old male who was originally admitted to the facility on [DATE]. Record review of Resident #1's history and physical dated 7/5/25, revealed that Resident #1 was admitted to a local hospital on 06/18 with altered mental status and neglect concerns. Resident #1 was diagnosed with a left middle cerebral artery (MCA) stroke (blocked blood flow to the brain), urinary tract infection (infection of the urinary system), and metabolic encephalopathy (confusion due to infection and chemical imbalance). Due to dysphagia (inability to swallow safely), the resident underwent placement of a PEG tube (feeding tube placed directly into the stomach) on 07/03, which was required for enteral nutrition and medication administration due to unsafe oral intake. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 07, indicating moderately impaired cognition. Review of Section GG indicated the resident required substantial assistance with self-care and mobility and was dependent on staff for multiple activities of daily living due to limited physical and cognitive functioning. The MDS documented that the resident had impaired swallowing ability and required altered nutritional support due to his inability to safely swallow food or medications. The MDS Section K for swallowing and nutritional status, paragraph B reflected that the resident had a feeding tube, indicating that oral intake was not safe and that enteral feeding (providing nutrition, fluids and medications directly into the stomach or intestines through a feeding tube) methods were required. Record review of Resident #1's care plan dated 10/13/2025 revealed that the resident required tube feeding related to dysphagia (trouble with swallowing) and was dependent on a PEG tube (a tube placed through the belly into the stomach so a person can get food, water, and medications when they cannot safely eat or swallow by mouth) for nutrition, hydration, and medication administration. The care plan revealed that the resident was not safe for oral intake and required staff to administer feedings and medications through the PEG. The care plan directed staff to monitor tube placement, perform daily site care, keep the head of bed elevated during and after feedings, and monitor for complications including aspiration (when food, liquid, or saliva accidentally enters the lungs, which can cause choking), infection, tube dislodgement (when the feeding tube comes out of place or gets pulled out), and intolerance of feedings. In an interview on 11/19/2025 at 10:32 AM, Resident #1 stated a nurse had given him the wrong medication. Resident #1 stated that he did not know which Page 1 of 12 675479 675479 11/25/2025 Franklin Heights Nursing & Rehabilitation 223 S Resler El Paso, TX 79912

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication it was, only that it was a white pill and a pink pill, and that the nurse placed the medication in his mouth for him to swallow. Resident #1 stated that his medications was supposed to be administered through his PEG tube per doctor's orders because it was not safe for him to swallow pills. The Resident said he told the staff he did not want the medications, but the nurse insisted he needed to take them, so he swallowed the pills. Resident #1 stated that after the staff gave him these medications, he reported the incident to a different nurse to make sure the right medications were being given to him. Resident #1 stated that after reviewing the medications he was supervised with, the nurse took him to the DON to report a medication error. Resident #1 stated that the staff monitored him for five days to make sure he did not develop complications from receiving the wrong medications. In an interview on 11/19/2025 at 10:55 AM with LVN A, he stated that when a resident is administered with medications by a CMA (certified medication assistant), the CMA is required to review the resident's medication orders and care plan to make sure they are following the physician's instructions. LVN A stated that failing to review a resident's care plan or medical record before giving medications could result in the resident receiving medications in a manner that is not consistent with their care needs. LVN A stated that not following a resident's care plan could lead to medication errors, a decline in the resident's condition, and the resident becoming ill if the wrong medications were given. In an interview on 11/19/2025 at 12:37 PM, the NP stated the medication error involving Resident #1 occurred because staff did not follow the resident's medication orders or his documented care plan. The NP stated that all CMAs, LVNs, and RNs was responsible for checking the resident's care plan before administering any medication to make sure the medication route and dosage matched the doctor's orders. The NP stated that the administered medication was an antiarrhythmic medication (a heart-rhythm-controlling drug) meant to lower the heart rate, and Resident #1 was not prescribed it. The NP stated that although the dosage was low, the resident was not supposed to receive that medication at all, and giving medications not listed on the care plan placed the resident at risk for changes in heart rate, blood pressure, or unexpected reactions. The NP stated that failing to follow the care plan was avoidable and could have resulted in a decline in the resident's condition if the wrong medications caused side effects or complications. The NP stated that he reminded staff of their responsibility to verify the care plan and orders each time medications was administered. Interviews were attempted on 11/20/2025 between 1:15 PM and 1:35 PM with CMA B to ask about the oversight on Resident # 1's review of his care plan that led to a medication error, but CMA B did not answer the phone. The investigator left a voicemail with identifying information, and a call back was requested. Phone calls were followed by a text message with identifying information requesting a call back, but CMA B did not contact the investigator. In an interview and observation conducted on 11/20/2025 at 1:30 PM, CMA C was observed administering medications for two residents. She explained that she followed procedures correctly by knocking on the resident's door, explaining the purpose of her visit, and assisting with required hygiene. CMA C stated she verified the 7 Rs (Right resident, Right medication, Right dose, Right route, Right time, Right reason, and Right documentation) before administering the medications. CMA C stated that CMAs was required to ensure the 7 Rs were always followed, and it was not acceptable to administer any medication that did not belong to the resident. She stated that failure to follow the 7 Rs could result in medication errors and potential harm to residents. In an interview on 11/20/2025 at 1:46 PM, the DON stated that all medication staff, including RNs, LVNs, and CMAs, was required to verify the physician's orders and the resident's care plan before administering any medications. The DON stated that staff was trained on medication pass and on the 7 rights of medication administration, which included confirming the right medication, route, 675479 Page 2 of 12 675479 11/25/2025 Franklin Heights Nursing & Rehabilitation 223 S Resler El Paso, TX 79912

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dose, and resident. The DON said all staff are trained on these upon hiring and as part of their annual training. The DON stated she became aware that CMA B administer medications for Resident #1 that was not part of his care plan. The DON stated that CMA B later admitted she had given the resident pills, despite earlier denying it. The DON stated CMA B confused residents, resulting in one resident receiving the wrong medication. The DON stated the failure to follow Resident #1's care plan was avoidable and that staff are responsible for reviewing the plan before medication administration. The DON stated that not following a resident's care plan could lead to declines in health, including changes in blood pressure or heart rate, and adverse reactions if medications are given incorrectly. In an interview on 11/21/2025 at 11:23 AM, LVN D stated Resident #1 had a g-tube and was barely starting to eat orally and the facility had not transitioned him to oral medications. LVN D stated the resident asked if CMA B was going to give him his medications orally moving forward and she informed him no, that only the RN or LVNs was responsible for administering medications through the g-tube per the resident's care plan. LVN D reported that Resident #1 told her that CMA B had given him medications orally. LVN D stated she asked CMA B about this, and CMA B denied administering anything. LVN D said she explained to CMA B that she needed to know what the resident had taken so he could be safely monitored according to the care plan. LVN D stated she asked the resident again what he received, and the resident reported a white and a pink pill. LVN D stated she questioned CMA B again, but CMA B continued to deny administering medications. LVN D stated she reported the matter to the DON, who initiated the investigation. LVN D stated after she reported CMA B's failure to follow Resident #1's care plan, CMA B was immediately removed from the floor. LVN D stated she notified the nurse practitioner and the resident's family, who expressed no immediate concerns. LVN D stated that CMAs, LVNs, and RNs are responsible for following the resident's care plan and medication administration records (MARs) to ensure medications are administered safely and by the correct route. LVN D stated that the possible negative outcomes for not following a resident's care plan could result in medication errors, delay of treatments or harm due to incorrect medication routes. In an interview conducted on 11/21/2025 at 11:35 AM, the Administrator reported awareness that LVN D had notified the DON that Resident #1 stated he had received oral medications from CMA B, despite the resident having a g-tube and not being cleared for oral medication administration in his care plan. The Administrator stated the care plan clearly required medications to be given through the g-tube by an RN or LVN and that CMA B should not have administered any oral medications. The Administrator reported that CMA B initially denied administering any medications but that, after continued questioning, an investigation was initiated immediately. The Administrator confirmed CMA B was pulled from the floor and eventually terminated. The Administrator stated that all CMAs, LVNs, and RNs are responsible for following the care plan and MAR to ensure medications are administered exactly as ordered. The Administrator said the possible negative outcomes for not following a care plan could result in a resident being administered an incorrect dosage of medication, deterioration of medical conditions and hospitalizations. Record review of the facility's policy and procedure titled Comprehensive Care Planning, not dated, read in part: Care Plan Development Develop and implement a person-centered comprehensive care plan for each resident based on the comprehensive assessment findings (including the MDS). Include measurable objectives and timeframes that address the resident's medical, nursing, mental, and psychosocial needs. Ensure the care plan describes: - Services needed to attain or maintain the resident's highest practicable well-being. - The resident's rights, including the right to refuse treatment. - Specialized services or rehabilitative services. The resident's goals for admission and desired outcomes. - The resident's preferences and potential for future discharge.Resident-Centered and 675479 Page 3 of 12 675479 11/25/2025 Franklin Heights Nursing & Rehabilitation 223 S Resler El Paso, TX 79912

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Preference-Based Care Ensure care plans are person-centered and reflect the resident's goals, preferences, strengths, and needs. Engage the resident and/or resident representative during development of the care plan and document participation or reasons participation was not practicable. Address risks, needs, or declines in condition, and document the rationale for the facility's decisions.Interdisciplinary Team (IDT) Responsibilities Ensure care plans are developed and reviewed by an Interdisciplinary Team, including the attending physician, RN, nurse aide, and appropriate staff from relevant disciplines. Ensure the care plan is revised based on changes in the resident's goals, preferences, needs, or clinical status.Ongoing Review and Updating Review and revise the resident's care plan: - After each Admission, Quarterly, Annual, or Significant Change MDS assessment. - Anytime goals, preferences, or clinical needs change. - Based on changes in the resident's response to interventions. Documentation Requirements Document the comprehensive care plan in the medical record. Describe the resident's goals, preferences, strengths, weaknesses, identified needs, and planned interventions. Document the facility's efforts to educate the resident/representative regarding risks of refusing treatment and efforts to find acceptable alternatives. Ensure reasons for declining care or treatment and associated risks are documented in the care 675479 Page 4 of 12 675479 11/25/2025 Franklin Heights Nursing & Rehabilitation 223 S Resler El Paso, TX 79912

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 acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 (Resident #1) reviewed for pharmacy services. The facility failed to follow physician's order by administering Amiodarone (a heart medication used to control dangerous irregular heartbeats) to Resident #1 when he was not prescribed this medication. This failure placed the residents at risk of not receiving their medications as ordered by the physician, which could cause a serious allergic reaction and side effects.The findings included: Record review of Resident #1's face sheet dated 11/20/2025 revealed an [AGE] year-old male who was originally admitted to the facility on [DATE]. Record review of Resident #1's history and physical dated 7/5/25, revealed that Resident #1 was an [AGE] year-old male admitted to a local hospital on 06/18 with altered mental status and neglect concerns. Resident #1 was diagnosed with a left middle cerebral artery (MCA) stroke (blocked blood flow to the brain), urinary tract infection (infection of the urinary system), and metabolic encephalopathy (confusion due to infection and chemical imbalance). Due to dysphagia (inability to swallow safely), the resident underwent placement of a PEG tube (feeding tube placed directly into the stomach) on 07/03, which was required for enteral nutrition and medication administration due to unsafe oral intake. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 07, indicating moderately impaired cognition. Review of Section GG indicated the resident required substantial assistance with self-care and mobility and was dependent on staff for multiple activities of daily living due to limited physical and cognitive functioning. The MDS documented that the resident had impaired swallowing ability and required altered nutritional support due to his inability to safely swallow food or medications. The MDS Section K for swallowing and nutritional status, paragraph B reflected that the resident had a feeding tube, indicating that oral intake was not safe and that enteral feeding (providing nutrition, fluids and medications directly into the stomach or intestines through a feeding tube) methods were required. Record review of Resident #1's care plan dated 10/13/2025 revealed that the resident required tube feeding related to dysphagia and was dependent on a PEG tube (feeding tube placed directly into the stomach) for nutrition, hydration, and medication administration. The care plan documented that the resident was not safe for oral intake and required staff to administer feedings and medications through the PEG tube. The care plan directed staff to monitor tube placement, perform daily site care, keep the head of bed elevated during and after feedings, and monitor for complications including aspiration, infection, tube dislodgement, and intolerance of feedings. Record review of the facility's Employee Disciplinary Report dated 10/16/2025, revealed CMA B was placed on an investigatory suspension pending an investigation into allegations of administering Resident # 1 the wrong medication. The form was signed by the Human Resources staff and CMA B on 10/16/25. In an interview on 11/19/2025 at 10:41 AM Resident #1stated that a nurse had given him the wrong medication. Resident #1 stated that he did not know which medication it was, only that it was a white pill and a pink pill, and that the nurse placed the medication in his mouth for him to swallow. Resident #1 stated that his medications were supposed to be administered through his PEG tube per doctor's orders because it was not safe for him to swallow pills. The Resident said he told the staff he did not want the medications, but the nurse insisted he needed to take them, so he swallowed the pills. Resident #1 stated that after the staff gave him these medications, he reported the incident to a different nurse to make sure the right medications were being given to him. Resident #1 stated that after reviewing 675479 Page 5 of 12 675479 11/25/2025 Franklin Heights Nursing & Rehabilitation 223 S Resler El Paso, TX 79912

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the medications he was supervised with, the nurse took him to the DON to report a medication error. Resident #1 stated that the staff monitored him for five days to make sure he did not develop complications from receiving the wrong medications. In an interview on 11/19/2025 at 10:55 AM, LVN A stated that CMAs (certified medication assistants) must verify a resident's medication orders before administering any medications to prevent medication errors. LVN A stated that reviewing the resident's care plan is also required to ensure medications are being given exactly as prescribed by following the seven R's that included the right dose, route, resident, medication, time and documentation. LVN A stated that when staff do not check the orders or the care plan, the risk of a medication error increases, which could cause the resident's health to worsen or make the resident sick if incorrect medication is administered. In an interview on 11/19/2025 at 12:37 PM, the NP stated that the resident experienced a medication error when he was given Amiodarone (a strong heart-rhythm medication used to treat dangerous irregular heartbeats) and Vitamin B12 (a vitamin used for anemia and nerve function), even though he was not prescribed either medication. The NP stated that Amiodarone can lower the heart rate and affect how the heart beats, and that giving it to someone who does not need it could cause dizziness, low blood pressure, weakness, or a dangerous change in heart rhythm. The NP stated the resident did not have any medical condition that would justify giving Amiodarone, making the error preventable. The NP stated he instructed the facility staff to check the residents' vitals throughout the day to make sure there were no negative reactions. The NP stated that all RNs, LVNs, and CMAs are required to verify the physician's orders before giving medications and that failing to do so places the resident at risk for harm. The NP stated that although the resident did not show an immediate reaction, the potential outcome of receiving unprescribed medications could have resulted in health complications such as dizziness, fainting and chest discomfort. Interviews was attempted on 11/20/2025 between 1:15 PM and 1:35 PM with CMA B to ask about the oversight on Resident # 1 review of his care plan that led to a medication error, but CMA B did not answer the phone. The investigator left a voicemail with identifying information, and a call back was requested. Phone calls were followed by a text message with identifying information requesting a call back, but CMA B did not contact the investigator. In an interview and observation conducted on 11/20/2025 at 1:30 PM, CMA C was observed reading the medication records for Resident # 2 and confirmed these medications were prescribed to the resident. CMA C explained to the investigator that CMAs need to confirm the seven Rs before supervising medications. CMA C stated that CMAs must never supervise medications to a resident if the medication was not ordered for them. CMA C stated that supervising the wrong medication such as Amlodipine to a resident who had not been prescribed with it could make the resident ill by lowering their blood pressure. She stated this could potentially result in injuries, dizziness, fainting, sickness, or hospitalization, depending on the resident's health condition. In an interview on 11/20/2025 at 1:46 PM, the DON stated she was notified that the CMA B had administered medications to Resident #1 that were not prescribed for him. The DON stated the incident involved Amiodarone (a heart-rhythm medication that slows the heart rate) and that the resident should not have been given any oral pills. The DON stated she immediately removed CMA B from the floor after learning that she confused residents while passing medications. The DON stated the physician was notified, and the Nurse Practitioner assessed Resident #1 to check for adverse reactions. The DON stated the resident's pulse was elevated due to anxiety but did not drop, and staff monitored his blood pressure for five days to ensure the medication error did not cause complications. The DON stated that administering unprescribed medications, especially Amiodarone, could cause a drop in blood pressure or heart rate, which could lead to health problems. The DON stated that RNs, LVNs, and CMAs are responsible for 675479 Page 6 of 12 675479 11/25/2025 Franklin Heights Nursing & Rehabilitation 223 S Resler El Paso, TX 79912

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few checking medication orders before administering any medications to prevent medication errors. Record review of the facility's in-services revealed that all staff from the facility had been trained on 10/16/25 by the DON on the 7 rights of medication administration, resident rights and Abuse Neglect and Exploitation. The DON stated that CMA B had been trained on all of these trainings upon being hired on April 7, 2023, and additionally, the DON had record of her observations of CMA B on 10/01/2025 where she had show proficiency on following the seven rights for medication administration, but CMA B had failed to comply with the training of the seven rights on 10/16/2025. In an interview on 11/21/2025 at 11:23 AM, LVN D reported that Resident #1 informed her he received medications orally from CMA B, specifically describing a white and a pink pill. LVN D stated the facility later identified that the medications involved were amiodarone, a medication used for heart rhythm problems such as atrial fibrillation (when the heart is beating out of rhythm), and vitamin B12, a nutritional supplement. LVN D reported that Resident #1 had a history of atrial fibrillation, and stated he was not at immediate risk from receiving amiodarone; however, she emphasized that he had no active order for amiodarone or oral medications at the time of the incident. LVN D reiterated that she questioned CMA B multiple times, but CMA B denied administering the medications. LVN D reported the incident to the DON and notified the NP and residents' family. LVN D stated that CMAs, LVNs, and RNs are responsible for verifying the MAR and prescriber orders before administering medications, ensuring accuracy, correct route, and resident safety. LVN D stated the potential negative outcomes from administering unprescribed or incorrect medications included allergic reactions, drug interactions, toxic effects due to unnecessary medications and hospitalizations. In an interview conducted on 11/21/2025 at 11:35 AM, the Administrator stated that the incident involved Resident #1 being administered oral amiodarone and vitamin B12 by CMA B, despite the resident not being prescribed those medications. The Administrator stated that Resident #1 reported receiving a white and a pink pill, which was later identified as those medications.The Administrator confirmed that amiodarone is a high-risk cardiac medication that should only be administered when prescribed and monitored. The Administrator stated that although the resident had a history of atrial fibrillation, he was not actively ordered amiodarone, making the administration a medication error. The Administrator emphasized that CMAs, LVNs, and RNs must always follow the MAR, check prescriber orders, and verify medication before administration, especially when supervising or administering high-risk medications. She stated the potential negative outcomes for administering amiodarone to a resident who did not need it could result in lowering the heard rate, dizziness and blood pressure drops which could complicate a residents' health. Record review of the facility's policy titled Medication Administration and General Guidelines, not dated, read in part: Medications be prepared, administered, and recorded only by licensed or otherwise legally authorized personnel who follow state regulations and facility procedures. Medications be administered exactly as ordered by the attending physician. If a dose appears incorrect, excessive, unclear, or inconsistent with the resident's condition, staff must contact the physician for clarification prior to administration. All current physician orders and medication schedules must be reflected on the resident's Medication Administration Record (MAR), and staff must verify each medication against the MAR before giving it. Staff must verify the identity of the correct resident using identification bands, photographs, the medical record, or verbal identification. Routine medications must be administered precisely as ordered, within one hour of the scheduled time, unless otherwise specified by the physician. If a medication is omitted, held, refused, or not given, staff must record the omission on the MAR, document the reason, and notify the physician as required. Staff must ensure the medication label matches the order on the MAR. If there is any discrepancy, unclear label, or 675479 Page 7 of 12 675479 11/25/2025 Franklin Heights Nursing & Rehabilitation 223 S Resler El Paso, TX 79912

F 0755 Level of Harm - Minimal harm or potential for actual harm questionable instruction, staff must not administer the medication until clarification is obtained. When medications require crushing, staff must follow manufacturer guidelines and ensure the MAR reflects that crushing is appropriate. Medications that are extended-release or enteric-coated must not be crushed. Staff must adhere to the Six Rights of Medication Administration:1. Right Dose2. Right Route3. Right Resident4. Right Medication5. Right Time6. Right Documentation Residents Affected - Few 675479 Page 8 of 12 675479 11/25/2025 Franklin Heights Nursing & Rehabilitation 223 S Resler El Paso, TX 79912

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 prevent significant medication errors for 1 of 7 residents (Resident #1) reviewed for pharmacy services. The facility failed to follow physician's order by administering Amiodarone (a heart medication used to control dangerous irregular heartbeats) to Resident #1 when he was not prescribed this medication. This failure placed the residents at risk of not receiving their medications as ordered by the physician, which could cause a serious allergic reaction and side effects.The findings included: Record review of Resident #1's face sheet dated 11/20/2025 revealed an [AGE] year-old male who was originally admitted to the facility on [DATE]. Record review of Resident #1's history and physical dated 7/5/25, revealed that Resident #1 was an [AGE] year-old male admitted to a local hospital on 06/18 with altered mental status and neglect concerns. Resident #1 was diagnosed with a left middle cerebral artery (MCA) stroke (blocked blood flow to the brain), urinary tract infection (infection of the urinary system), and metabolic encephalopathy (confusion due to infection and chemical imbalance). Due to dysphagia (inability to swallow safely), the resident underwent placement of a PEG tube (feeding tube placed directly into the stomach) on 07/03, which was required for enteral nutrition and medication administration due to unsafe oral intake. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 07, indicating moderately impaired cognition. Review of Section GG indicated the resident required substantial assistance with self-care and mobility and was dependent on staff for multiple activities of daily living due to limited physical and cognitive functioning. The MDS documented that the resident had impaired swallowing ability and required altered nutritional support due to his inability to safely swallow food or medications. The MDS Section K for swallowing and nutritional status, paragraph B reflected that the resident had a feeding tube, indicating that oral intake was not safe and that enteral feeding (providing nutrition, fluids and medications directly into the stomach or intestines through a feeding tube) methods were required. Record review of Resident #1's care plan dated 10/13/2025 revealed that the resident required tube feeding related to dysphagia and was dependent on a PEG tube (feeding tube placed directly into the stomach) for nutrition, hydration, and medication administration. The care plan documented that the resident was not safe for oral intake and required staff to administer feedings and medications through the PEG tube. The care plan directed staff to monitor tube placement, perform daily site care, keep the head of bed elevated during and after feedings, and monitor for complications including aspiration, infection, tube dislodgement, and intolerance of feedings. Record review of the facility's Employee Disciplinary Report dated 10/16/2025, revealed CMA B was placed on an investigatory suspension pending an investigation into allegations of administering Resident # 1 the wrong medication. The form was signed by the Human Resources staff and CMA B on 10/16/25. In an interview on 11/19/2025 at 10:41 AM Resident #1stated that a nurse had given him the wrong medication. Resident #1 stated that he did not know which medication it was, only that it was a white pill and a pink pill, and that the nurse placed the medication in his mouth for him to swallow. Resident #1 stated that his medications were supposed to be administered through his PEG tube per doctor's orders because it was not safe for him to swallow pills. The Resident said he told the staff he did not want the medications, but the nurse insisted he needed to take them, so he swallowed the pills. Resident #1 stated that after the staff gave him these medications, he reported the incident to a different nurse to make sure the right medications were being given to him. Resident #1 stated that after reviewing the medications he was supervised with, the nurse took him to the DON to report a medication error. Resident #1 stated that the staff monitored him for five days to make sure he did not develop Residents Affected - Few 675479 Page 9 of 12 675479 11/25/2025 Franklin Heights Nursing & Rehabilitation 223 S Resler El Paso, TX 79912

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few complications from receiving the wrong medications. In an interview on 11/19/2025 at 10:55 AM, LVN A stated that CMAs (certified medication assistants) must verify a resident's medication orders before administering any medications to prevent medication errors. LVN A stated that reviewing the resident's care plan is also required to ensure medications are being given exactly as prescribed by following the seven R's that included the right dose, route, resident, medication, time and documentation. LVN A stated that when staff do not check the orders or the care plan, the risk of a medication error increases, which could cause the resident's health to worsen or make the resident sick if incorrect medication is administered. In an interview on 11/19/2025 at 12:37 PM, the NP stated that the resident experienced a medication error when he was given Amiodarone (a strong heart-rhythm medication used to treat dangerous irregular heartbeats) and Vitamin B12 (a vitamin used for anemia and nerve function), even though he was not prescribed either medication. The NP stated that Amiodarone can lower the heart rate and affect how the heart beats, and that giving it to someone who does not need it could cause dizziness, low blood pressure, weakness, or a dangerous change in heart rhythm. The NP stated the resident did not have any medical condition that would justify giving Amiodarone, making the error preventable. The NP stated he instructed the facility staff to check the residents' vitals throughout the day to make sure there were no negative reactions. The NP stated that all RNs, LVNs, and CMAs are required to verify the physician's orders before giving medications and that failing to do so places the resident at risk for harm. The NP stated that although the resident did not show an immediate reaction, the potential outcome of receiving unprescribed medications could have resulted in health complications such as dizziness, fainting and chest discomfort. Interviews was attempted on 11/20/2025 between 1:15 PM and 1:35 PM with CMA B to ask about the oversight on Resident # 1 review of his care plan that led to a medication error, but CMA B did not answer the phone. The investigator left a voicemail with identifying information, and a call back was requested. Phone calls were followed by a text message with identifying information requesting a call back, but CMA B did not contact the investigator. In an interview and observation conducted on 11/20/2025 at 1:30 PM, CMA C was observed reading the medication records for Resident # 2 and confirmed these medications were prescribed to the resident. CMA C explained to the investigator that CMAs need to confirm the seven Rs before supervising medications. CMA C stated that CMAs must never supervise medications to a resident if the medication was not ordered for them. CMA C stated that supervising the wrong medication such as Amlodipine to a resident who had not been prescribed with it could make the resident ill by lowering their blood pressure. She stated this could potentially result in injuries, dizziness, fainting, sickness, or hospitalization, depending on the resident's health condition. In an interview on 11/20/2025 at 1:46 PM, the DON stated she was notified that the CMA B had administered medications to Resident #1 that were not prescribed for him. The DON stated the incident involved Amiodarone (a heart-rhythm medication that slows the heart rate) and that the resident should not have been given any oral pills. The DON stated she immediately removed CMA B from the floor after learning that she confused residents while passing medications. The DON stated the physician was notified, and the Nurse Practitioner assessed Resident #1 to check for adverse reactions. The DON stated the resident's pulse was elevated due to anxiety but did not drop, and staff monitored his blood pressure for five days to ensure the medication error did not cause complications. The DON stated that administering unprescribed medications, especially Amiodarone, could cause a drop in blood pressure or heart rate, which could lead to health problems. The DON stated that RNs, LVNs, and CMAs are responsible for checking medication orders before administering any medications to prevent medication errors. Record review of the facility's in-services revealed that all staff from the facility had been trained on 675479 Page 10 of 12 675479 11/25/2025 Franklin Heights Nursing & Rehabilitation 223 S Resler El Paso, TX 79912

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10/16/25 by the DON on the 7 rights of medication administration, resident rights and Abuse Neglect and Exploitation. The DON stated that CMA B had been trained on all of these trainings upon being hired on April 7, 2023, and additionally, the DON had record of her observations of CMA B on 10/01/2025 where she had show proficiency on following the seven rights for medication administration, but CMA B had failed to comply with the training of the seven rights on 10/16/2025. In an interview on 11/21/2025 at 11:23 AM, LVN D reported that Resident #1 informed her he received medications orally from CMA B, specifically describing a white and a pink pill. LVN D stated the facility later identified that the medications involved were amiodarone, a medication used for heart rhythm problems such as atrial fibrillation (when the heart is beating out of rhythm), and vitamin B12, a nutritional supplement. LVN D reported that Resident #1 had a history of atrial fibrillation, and stated he was not at immediate risk from receiving amiodarone; however, she emphasized that he had no active order for amiodarone or oral medications at the time of the incident. LVN D reiterated that she questioned CMA B multiple times, but CMA B denied administering the medications. LVN D reported the incident to the DON and notified the NP and residents' family. LVN D stated that CMAs, LVNs, and RNs are responsible for verifying the MAR and prescriber orders before administering medications, ensuring accuracy, correct route, and resident safety. LVN D stated the potential negative outcomes from administering unprescribed or incorrect medications included allergic reactions, drug interactions, toxic effects due to unnecessary medications and hospitalizations. In an interview conducted on 11/21/2025 at 11:35 AM, the Administrator stated that the incident involved Resident #1 being administered oral amiodarone and vitamin B12 by CMA B, despite the resident not being prescribed those medications. The Administrator stated that Resident #1 reported receiving a white and a pink pill, which was later identified as those medications.The Administrator confirmed that amiodarone is a high-risk cardiac medication that should only be administered when prescribed and monitored. The Administrator stated that although the resident had a history of atrial fibrillation, he was not actively ordered amiodarone, making the administration a medication error. The Administrator emphasized that CMAs, LVNs, and RNs must always follow the MAR, check prescriber orders, and verify medication before administration, especially when supervising or administering high-risk medications. She stated the potential negative outcomes for administering amiodarone to a resident who did not need it could result in lowering the heard rate, dizziness and blood pressure drops which could complicate a residents' health. Record review of the facility's policy titled Medication Administration and General Guidelines, not dated, read in part: Medications be prepared, administered, and recorded only by licensed or otherwise legally authorized personnel who follow state regulations and facility procedures. Medications be administered exactly as ordered by the attending physician. If a dose appears incorrect, excessive, unclear, or inconsistent with the resident's condition, staff must contact the physician for clarification prior to administration. All current physician orders and medication schedules must be reflected on the resident's Medication Administration Record (MAR), and staff must verify each medication against the MAR before giving it. Staff must verify the identity of the correct resident using identification bands, photographs, the medical record, or verbal identification. Routine medications must be administered precisely as ordered, within one hour of the scheduled time, unless otherwise specified by the physician. If a medication is omitted, held, refused, or not given, staff must record the omission on the MAR, document the reason, and notify the physician as required. Staff must ensure the medication label matches the order on the MAR. If there is any discrepancy, unclear label, or questionable instruction, staff must not administer the medication until clarification is obtained. When medications require crushing, staff must follow manufacturer guidelines and ensure the MAR reflects 675479 Page 11 of 12 675479 11/25/2025 Franklin Heights Nursing & Rehabilitation 223 S Resler El Paso, TX 79912

F 0760 Level of Harm - Minimal harm or potential for actual harm that crushing is appropriate. Medications that are extended-release or enteric-coated must not be crushed. Staff must adhere to the Six Rights of Medication Administration:1. Right Dose2. Right Route3. Right Resident4. Right Medication5. Right Time6. Right Documentation Residents Affected - Few 675479 Page 12 of 12