Health inspection·July 3, 2025

F 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and [Resident #]1 has pulmonary edema, and pneumonia. Notified the results to RR, FNP who ordered IV Rocephin 1 g daily for 5 days. RN W documented on 6/28/25 at 1:30 AM [Resident #1] was given food by the day CNA (cannot specified) and chest x-ray taken due to that although it came negative but showed Resident #1 has pneumonia and is on Rocephin. RN W administered Resident #1's first dose.Record Review of Resident #1's hospital records dated 4/26/2025 revealed Resident #1 Peg evaluation, Aspiration pneumonia (a lung infection that develops when food, liquids, or other foreign materials are inhaled into the lungs, causing inflammation and infection), dysphagia, has failed swallow evaluations.Record Review of Resident #1's hospital records dated 4/27/2025 revealed Resident #1 underwent EGD (procedure that uses a camera to examine the esophagus) with PEG placement on 4/23.20 French PEG placement (a feeding tube that is 20 inch in diameter) was successfully completed. Record review of Resident #1 hospital discharge orders revealed Diet: NPO.hydration/water.125ml/q4hrs.continuous tube feeding.Jevity 1.2.rate 60. Record Review of Resident #1's Xray report, dated 6/19/25, revealed Subtle patchy opacity (a faint or indistinct area of increased density) is seen in the right upper lung and left lower lung. This could be due to pulmonary edema (a condition where fluid builds up in the lungs, making it difficult to breathe), atelectasis (Complete or partial collapse of a lung or a section (lobe) of a lung) and/or pneumonia (an infection that inflames the air sacs in one or both lungs).Record Review of Resident #1's Xray report, dated 6/27/25 revealed Subtle patchy opacity (a faint or indistinct area of increased density) is seen in the right upper lung and left lower lung. This could be due to pulmonary edema (a condition where fluid builds up in the lungs, making it difficult to breathe), atelectasis (Complete or partial collapse of a lung or a section (lobe) of a lung) and/or pneumonia (an infection that inflames the air sacs in one or both lungs).Record review of Resident #1's dietary ticket, dated 6/27/25, revealed: NPO/PureeBeverage texture: NectarDuring an interview on 7/1/25 at 3:41 PM, Resident #1 only answered yes and no questions. She answered yes to receiving a tray on 6/27/25, consuming the food on the tray in its entirety, to the food being good and being able to consume the food without complication. She answered no to being in any pain and she stated no when asked was she to receive a tray on 6/27/25. During interviews conducted on 07/01/25 at 9:00 AM, the ADM stated CNA A gave Resident #1 a tray that contained pureed food. She stated CNA C reported the incident to RN W on 6/27/25. The ADM stated after investigating the incident, she found that the vendor that was used for dietary needs was implementing a system update which made it impossible to print the dietary tickets for the facility. She stated the system to print the tickets had never been down before. She stated the vendor had to print the dietary tickets for the facility and when the tickets were printed, Resident #1's, who was actively in NPO status, because she received her nutrition via PEG tube, ticket was printed and included with the remainder of the facility resident dietary tickets. She stated initially CNA C assumed Resident #1 received regular textured food because CNA C knew other residents received regular textured food. The ADM stated that she spoke with CNA A who stated that the food that she served Resident #1 was pureed and described it as that slurpee stuff. The ADM stated when she interviewed CNA A, she inquired what happened and she was told by CNA A that she read the ticket and was surprised because Resident #1 did not usually get a tray. The ADM stated CNA A stated she consulted with CNA B and CNA B told CNA A to leave the tray for Resident #1. The ADM stated Resident #1 received her PEG tube at the end of the April 2025, and since then, Resident #1 had been crying because she wanted to eat. The ADM stated she reported the incident to state because CNA C stated it was negligent and Resident #1 should not have received a tray of food because she was NPO. During an interview conducted on 07/01/25 at 9:10 AM, the DON stated Resident #1 had a PEG tube in place on 6/27/25. The DON stated Resident #1 had the PEG placed in April 2025 due (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675527 If continuation sheet Page 2 of 8 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 675527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to ongoing stomach issues and she was experiencing pain. The DON stated Resident #1 also had a history of pneumonia. The DON stated ever since the PEG placement, Resident #1 had been crying because she wanted to eat. The DON stated when Resident #1 received a tray on 6/27/25 and RN W was notified, he (RN W) notified facility management, RR, the MD and ordered an x-ray. She stated RN W reported to her that the x-ray did not have any significant findings. The DON stated that she was told by RN W that there were signs of pneumonia, but it was lingering pneumonia from a previous diagnosis. The DON stated Rocephin was ordered, and the first dose was given that night. The DON stated there were no signs of aspiration. The DON stated since 6/27/25, the orders for Resident #1 were changed and Resident #1 was actively able to consume food orally. She stated when Resident #1 consumed her meal, a staff sat with her and a nurse was present during the meal. During an interview conducted on 07/01/25 at 11:25 AM, CNA A stated on 6/27/25 they (she and CNA B) were passing out trays. She stated she received the tray for Resident #1. She stated it was not whole food. She described the food as food that you slurped up and it looked like baby food. CNA A stated that she did not believe a nurse checked the trays before the resident trays were brought to the hall. CNA A stated she looked at the dietary ticket for Resident #1 and remember seeing her name on the ticket, but did not remember seeing anything else. She stated after she saw that Resident #1 had a tray, she consulted with CNA B, and she was told by CNA B to leave the tray with Resident #1. CNA A stated she left the tray, but did not see her consume the food on the tray. She stated she did not know if Resident #1 consumed the entire tray of food or not because their shift did not pick up the trays. She stated the potential negative outcome was Resident #1 could have choked or died. She stated her nurse would have been LVN L, but LVN L did not bring the resident trays to the hall. CNA A stated that the dietary staff (did not know which one) brought the trays on 6/27/25. CNA A stated she was a newer staff and had been employed at the facility for about three weeks. She stated she had only been a CNA for a brief time. She stated she did not realize Resident #1 receiving the tray of food was an issue until the ADM called her the following day (6/28/25) and asked her about the incident. CNA A stated she was told that when she returned, she was instructed to give a statement. CNA A stated she gave Resident #1 the food because she did not know Resident #1 could not have food. She was unaware that she had a PEG tube for her nutrition. She stated she later found out Resident #1 had a PEG tube when the ADM called her. She stated there were no other residents with PEG tube placements. She stated she did not contact or consult a nurse. She stated after consulting CNA B, she thought it was ok. She stated CNA B had been with the facility longer than her. CNA A stated she did not have access to the facility's EMR/PCC at the time of the incident (6/27/25). She stated she just received access not to long before the interview but did not remember the exact date. She stated the facility process of checking the trays was the nurse would check the trays in the dining room. She stated dietary staff brought the trays to the hall normally. She stated they (CNAs) checked the dietary ticket for the name and served the tray. She stated on 6/27/25, she was floating between halls and not assigned to any hall. She stated she had been trained that NPO meant nothing by mouth, and she would know if someone was NPO if the resident had a feeding tube.During interviews conducted on 07/01/25 at 12:18 PM, CNA B stated NPO meant the resident could not be fed by mouth. CNA B stated she was never officially told that Resident #1 was NPO, but she assumed she was because Resident #1 never received a tray since she had worked at the facility. She stated she had worked at the facility for at least a month. CNA B stated there were no other residents in the facility that were NPO status. CNA B stated she was unaware that Resident #1 received a tray on 6/27/25. She stated she found out about the incident on 6/28/25 when she was asked who gave Resident #1 a tray. She stated the night/evening staff picked up the tray and that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675527 If continuation sheet Page 3 of 8 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 675527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was how they (nighttime staff) found it. CNA B stated she worked with CNA A on 6/27/25. She stated CNA A did not consult her (CNA B) about giving Resident #1 the tray. CNA B stated she could not recall telling CNA A anything about leaving the tray for Resident #1. She stated at the time of the incident she did not receive any additional training or instruction about Resident #1 or about any residents that could not eat. She stated they (staff that worked 6/28/25) were told that Resident #1 was not to receive a tray on 6/27/25. CNA B stated she was unsure if the tray was checked by a nurse on 6/26/25. She stated she could not remember who the nurse was on 6/26/25. She stated the facility process for administering the trays to the resident during mealtimes was the nurse should check the trays in the dining room but not the trays on the hall. CNA B stated she had never had any issues with the trays being wrong on the halls. She stated the staff from dietary brought the resident trays from dining room to the halls to serve to the residents that eat in their rooms. She stated it was different staff each time, but always dietary staff. During interviews conducted on 07/01/25 at 1:23 PM, DA P stated he had been trained that NPO was nothing by mouth. He stated he knew a resident was NPO based off the dietary ticket. He stated if a resident was NPO, they (residents) should not have a dietary ticket. He stated if the saw on a ticket conflicting information he was unsure what to do. He stated he was not present on 6/27/25 when Resident #1 received a tray. He stated the facility process for distributing resident trays was the nurse checked the tray. He stated they (dietary staff) was not to serve until a nurse was in the dining room. He stated the nurse was to take the trays to the hall for the residents that eat in their room. He stated in the dining room, the nurse checked the tray and handed it to the CAN and the CNA would then distribute to the residents. He stated he was unsure if the CNAs were checking in addition to the nurse checking. During interviews conducted on 07/01/25 at 12:18 PM, DA Q stated NPO was nothing by mouth. He stated they (dietary staff) knew when a resident was NPO because it should say it on the resident's dietary ticket. He stated if he saw a diet texture and NPO on a ticket he would contact a charge nurse so that they (dietary and clinical staff) could figure it out together. DA Q stated he was not working on 6/27/25 and was unaware that Resident #1 had a PEG tube. He stated the facility process for distributing trays to residents was the nurse would sometimes check the tray before. He stated the nurses sometimes were busy. He stated there were times when the CNA would grab the tray and go. He stated, the majority of the time, the nurse checked the tray before distribution. He stated the trays that went to the halls were checked half the time. He stated he was unsure what the nurses checked for on residents' trays. During interviews conducted on 07/01/25 at 1:51 PM, the DM stated NPO meant nothing by mouth and the dietary staff know because if there was a change, then the nurse would send the dietary department a communication form so that the dietary cards were updated. The DM stated whether they (residents) eat their food or not each resident should have a dietary card. She stated if the resident was NPO then they (residents) should not have a dietary card. She stated when they (dietary staff) print out the dietary cards Resident #1's card did not normally print out when they (dietary staff) printed them out. She stated she was unsure why when the vendor printed the dietary tickets for them (dietary staff) Resident #1 had a dietary card to print out. She stated on 6/27/25, during breakfast and lunch, she assisted the dietary staff with ensuring that all residents received the appropriate diet. She stated the vendor printed the tickets out for supper, she handed the dietary tickets to the dietary staff, and did not check the tickets for accuracy. She did not have a reason she did not check the tickets. She stated she did not think about checking the tickets for accuracy. She stated she left at 5:00 PM on 6/27/25 and was not present when the dietary staff prepared Resident #1 tray. She stated [NAME] T would have been the only staff that she would have thought that did not know that Resident #1 did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675527 If continuation sheet Page 4 of 8 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 675527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few not consume food orally. She stated DA R, and DA S would have known Resident #1 did not consume food orally because they had worked at the facility for a while. She stated once they (dietary staff) saw the ticket they (dietary staff) should have questioned the ticket. She stated the ticket first went to the cook who would place the entre on the plate. The DM stated that the cook was looking for the texture and should be checking the dietary ticket in its entirety. The DM stated then the plate goes to the first dietary aide who was added things such as vegetables and any other sides. The DM stated the first dietary aide was continuing the correct texture that was listed on the ticket and should also be checking the dietary ticket in its entirety. She stated each dietary staff would have had the opportunity to identify on Resident #1's ticket that she was NPO. The DM stated the dietary staff should have consulted with the charge nurse on 6/27/25 when they (dietary staff) observed a diet texture and the status of NPO listed. The DM stated then the last part of the plating process was the last/second dietary aide would add things such as drinks, bread, and desserts. They (dietary staff) would hand the tray to the nurse or place it on the cart for the tray to go to the hall. She stated the second dietary aide should also be checking the dietary ticket in its entirety. The DM stated Resident #1 had never received a tray while on NPO status. The DM stated they (the facility) had never had issues with their system before. She stated when she gave the dietary workers the dietary tickets, she was unaware Resident #1 had a ticket. The DM stated the potential negative outcome for serving Resident #1 a tray, when she was not supposed to, was that she could have choked, aspirated, and possibly died. The DM stated she was unsure if Resident #1's tray was checked on 6/27/25. The DM stated she expected the residents to receive the correct meal on their ticket and if they (residents) were not to have a meal, then they (residents) should not receive one. The DM stated she was never at the facility for dinner because she left at 5:00 PM daily. She stated she was present during breakfast and lunch, and she normally observed dietary staff checking the dietary tickets and nurses checking the trays before distribution to the residents. During interviews conducted on 07/01/25 at 2:37 PM, [NAME] T stated he worked on 6/27/25, but he did not know specifically who Resident #1 was until after she was served and management addressed them (dietary staff). He stated he was new and was at the beginning of the plating process. He stated after him the plate would go through, two other workers and then a CNA would check it. [NAME] T stated he did not remember reading Resident #1's ticket. He stated he normally looks at the texture but did not remember seeing NPO on Resident #1's ticket. [NAME] T stated he was told/trained by the DM that NPO meant that the resident could not receive anything by mouth and received their nutrition by tube. [NAME] T stated even if he had seen NPO he may not have done anything different because he was not made aware of the NPO status until after the incident. He stated he was trained on NPO and the incident the day after the incident before his shift started. He stated he recently learned that he was to look at the entire dietary ticket. [NAME] T stated he knew to ask questions if he needed to, and would, moving forward. [NAME] T stated he was still new and stated he honestly could not tell the difference between the CNAs or the nurses as he was a newer employee. [NAME] T stated he had only worked at the nursing facility for 2-3 weeks. During interviews conducted on 07/01/25 at 2:39 PM, LVN L stated she knew what NPO was and that it meant nothing by mouth. She stated she knew that a resident had the status of NPO when it was listed in the residents' chart. She stated they (facility staff) were also told during shift change if a person received a new order of NPO. She stated the staff would have access to NPO information in the EMR. LVN L stated she was unaware that Resident #1 had been given a tray by CNA A because she did not remember which CNAs worked on 6/27/25, and she was not told that Resident #1 received a tray. She stated on 6/28/25 she received the information during shift change in report from RN W. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675527 If continuation sheet Page 5 of 8 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 675527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few RN W stated that Resident #1 received a tray. LVN L stated she did not monitor the dining room on 6/27/25 during dinner time. She stated she monitored breakfast, and Resident #1 did not receive a tray during breakfast on 6/27/25. She stated LVN O would have been the other nurse on duty. She stated she was unaware if he was in the dining room, or if the dining room trays were checked before the resident trays went to the hallway. She stated that there were only two nurses on duty, and they (LVN L and LVN O) were training other nurses that day. LVN L stated she had never seen Resident #1 consume food or receive a tray. LVN L stated she did not receive any specialized training because of the incident. She stated the facility process for distributing resident trays was once the tray came off the line, the nurse checked the ticket against the tray for accuracy. She stated the nurse was checking to make sure the resident had the correct diet texture. She stated then they (nurses) gave the tray to a CNA to distribute. LVN L stated the cook for that day was new and she remembered the system that dietary used was down, but she did not have much information about it. LVN L stated she was aware that Resident #1 had a PEG and was NPO. She stated Resident #1 had a PEG tube because she had stomach issues, but she was unsure of the details and specifics. She stated when she checked the ticket, she checked the dietary ticket in its entirety for the correct resident and diet details. During interviews conducted on 07/01/25 at 3:16 PM, DA R stated NPO meant the resident could not have anything by mouth. He stated they (dietary staff) knew when a resident was NPO because the nurses told them (dietary staff), and it would indicate the information on the dietary ticket. He stated he knew Resident #1 did not eat and knew who she was. DA R stated he was aware that Resident #1 was NPO. He stated he observed her ticket on 6/27/25 and saw she was to receive a pureed tray and that was why he was served one. DA R stated their cook (Cook T) was new but since he made the plate for Resident #1, he assumed that it was ok. DA R stated he was unsure if the trays were checked by a nurse but did not remember seeing a nurse. DA R stated the facility process in distributing trays was the nurse was to check the tray before it was served to the resident. He stated on 6/27/25, he took the tray to the Hall were Resident #1 resided and this was because they (dietary staff) did not see a nurse. He stated once he took the cart to the hall, it would have been the nurse's aides to serve the trays to the residents. He stated that when it was time to serve meals, the dietary staff announced the mealtime over the loudspeaker. He stated he had not received any additional training regarding the incident. He stated when he checked the dietary ticket, he looked at the ticket in its entirety. He stated he did not see the word NPO on the ticket on 6/27/25. During interviews conducted on 07/01/25 at 4:50 PM, RN W stated NPO meant nothing by mouth and the resident was not allowed to have anything by mouth. He stated that he knew a resident was NPO because of the MAR, EMR, or PCC. He stated he was aware that Resident #1 was NPO. RN W stated he worked the night shift on 6/27/25. He stated he was notified by CNA C that Resident #1 hit her call light for her tray to be picked up. RN W stated CNA C reported that the tray was empty when she picked up Resident #1's tray. RN W stated when he went to see Resident #1, he observed red Kool-Aid on her face. He stated he notified management, the MD, and the RR. He stated the MD ordered an x-ray. He stated the x-ray was completed and it showed that she had lingering pneumonia but no signs of aspiration. RN W stated Resident #1 had pneumonia in the past and had received treatment, so the MD ordered IV Rocephin and he administered the medication the night of 6/27/25. He stated when he started his shift on 6/27/25 at 6:00 PM, LVN L gave him report and it did not include any information about Resident #1 receiving a tray of food. RN W stated he would not have been responsible for any meal monitoring because when he arrived at the facility, dinner would have already started as it started at 5:00 PM. He stated the evening/night shift were only responsible for passing out snacks and picking up dinner trays if there were any left. He stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675527 If continuation sheet Page 6 of 8 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 675527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few when he reported the incident to the DON, the DON told him she would educate the staff. RN W stated he immediately verbally educated his staff on what NPO was and the importance. During an interview on 7/01/2025 at 10:24am with Resident #1's Guardian, she stated she had received a call during the weekend and was told Resident #1 had been served a tray of food although she was NPO. She stated Resident #1 had been placed on NPO after a PEG placement due to recurrent GI issues and recurrent aspiration pneumonia. She stated Resident #1 had not had any food since she had the PEG tube placed and had a decrease in quality of life, but as of 6/30/2025, Resident #1 had the PEG tube removed by hospice and was allowed pleasure feedings. During an interview on 7/01/2025 at 4:51 pm with the MD, he stated he had been made aware of the incident that occurred on 6/27/2025 with Resident #1, and from his understanding, there had been no complications from the incident. He stated he expected the staff at the facility to follow the diet orders for each resident. He stated the potential negative outcome of Resident #1 receiving the incorrect diet could have been aspiration pneumonia). The MD stated Resident #1 had a diaphragmatic hernia and the PEG tube had been placed because Resident #1 was having reflux (referred to the backward flow of stomach contents into the esophagus), and there were concerns about possible aspiration. The MD stated he had spoken to the ADM (unknown date) and the ADM would be ensuring all the diet orders were reviewed for accuracy with the kitchen staff and with the floor staff. The MD stated after speaking with Resident #1's guardian, they decided Resident #1 would have the PEG tube removed.During interviews conducted on 07/02/25 at 12:55 PM, the DON stated if the vendor's system was to stop working again, the facility intended to address the issue by ensuring the dietary staff knew to report the issue to the DM, DON, and ADM. She stated once they (management staff) were notified, they (DON/ADM) would work with the DM and dietary staff comparing the diet orders in the EMR/PCC to what the dietary staff had. She stated on 6/27/25, there were two nurses on duty, and they (LVN L and LVN O) were training two new nurses. She stated if there were three nurses then they (nurses on duty) would have split the mealtimes equally (1 nurse per mealtime). She stated if there would have been two nurses then they (nurses on duty) should have had one meal monitoring per nurse and split the dinner meal to monitor. She stated the nurses should have communicated to ensure monitoring for dinner was conducted by a nurse on 6/27/25. She stated on 6/27/25, there was no specific nurse assigned to dinner mealtime monitoring. She stated the nurses that were on duty (not the nurses that were being trained) would have been responsible. She stated it would have been between LVN L and LVN O who would have been responsible for monitoring the dinner mealtime. She stated the facility process was that nurses assigned to certain halls had specific meals that they (nurses on duty) were responsible for. The DON stated on 6/27/25, Resident #1 should not have received a tray of food, and should not have had a dietary ticket. She stated at the time, the dietary or clinical staff noticed that Resident #1 received a dietary ticket or there was a discrepancy on her dietary ticket they (the dietary and clinical staff) should have notified the DM and or a charge nurse. The DON stated the DM should have checked the dietary tickets for accuracy before giving the dietary tickets to the dietary staff. The DON stated that she did not see Resident #1's dietary ticket, but was told by the DM that the ticket indicated Resident #1 was NPO and could receive a pureed diet texture. The DON stated when there was conflicting information, the staff had been trained to verify with a charge nurse. The DON stated Resident #1 was NPO on 6/27/25. The DON stated Resident #1 had her PEG tube placed in April 2025 because she had aspiration pneumonia in the past. It was determined that it was safest if she had the PEG placed. The DON stated Resident #1 had dysphasia. She stated Resident #1 was once on mechanical soft and because she was having difficulty swallowing, she was moved to pureed. The DON stated when Resident #1 would consume the mechanical soft, she would have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675527 If continuation sheet Page 7 of 8 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 675527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete increased coughing. The DON stated Resident #1 even vomited a few times. The DON stated all the staff had been trained by her, the ADM, and the DM except for some of the nighttime shift. She stated the nighttime shift would be trained before they (nighttime shift) were allowed to work their shift. The DON stated she was familiar with the facility's policies related to dietary services and residents receiving the correct prescribed therapeutic diet. She stated the purpose of having the correct diet and having a policy for therapeutic diet was for resident safety and to prevent choking. She stated the potential negative outcome for not following the policies, or ensuring the residents have the correct diet, was the resident could choke or aspirate. She stated that residents could potentially not receive the nutrition they (residents at the facility) needed and could experience weight loss. The DON stated, on 6/27/25, she was unaware that Resident #1 had received a tray of food while she was ordered to be NPO. She stated she was unaware that CNA A was not following the physician order for Resident #1. She stated the system to monitor or ensure that staff were following the physicians order for diets, was once the MD ordered the diet, then it was entered in the EMR/PCC. The nursing staff then reported the change to dietary via communication form. She stated the CNAs were informed because the information was accessible in the EMR/PCC. She stated she and her staff had been trained regarding residents receiving the correct diet per physicians' orders. She stated she expected for all staff to follow the physician orders and for all residents to receive their meal as ordered by the physician. The DON stated the reason Resident #1 received the tray when she was not supposed to was because the vendor generated a dietary ticket, and the tray was not checked. She stated the dietary staff, and clinical staff should have asked the nurse about any discrepancies. The DON confirmed that CNA A had access to the facility EMR/PCC as of 6/24/25. During interviews conducted on 07/02/25 at 2:50 PM, the ADM stated if the system that dietary used to print dietary tickets goes down again, they (the ADM, DON, and DM) would ensure to check all tickets printed from the vendor for accuracy. The ADM stated on 6/27/25 one of the charge nurses on duty would have been responsible for monitoring the dinner mealtime. She stated it would have been between LVN L and LVN O. The ADM stated that the nurses would have known who was responsible for the meal monitoring based off the scheduling system created by the DON and ADON. The ADM stated, on 6/27/25, what should have happened was at the moment the staff observed Resident #1 had a dietary ticket and that it had a diet texture and listed as NPO, they (the clinical and Event ID: Facility ID: 675527 If continuation sheet Page 8 of 8