Health inspection·October 31, 2025

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1's Family Member D said she expressed concerns to Nurse A about the resident having the same symptoms in the hospital and he was dehydrated, and his potassium was low. Nurse A said she would get labs in the morning. Resident #1's Family Member D went and got the resident some Gatorade and then went home. She received a call on [DATE] at 5:00 am saying he had passed. In an interview on [DATE] at 11:55 am, Nurse A said Resident #1's Family Member D came and got her stating Resident #1's breathing was different, and he did not look good. Nurse A stated she told Resident #1's Family Member D that Resident #1 had lots of fluids that day (passing watery stools) and had to change his ostomy bag several times. She said she took his vital signs but could not remember them exactly, but his vitals were low but not extremely low. Nurse A said she did not see that his breathing was different, it was not labored, and he was talking to me and did not express any complaints. She said the resident passing lots of fluids was a new symptom for Resident #1 that had started on that day, [DATE] and had not had that symptom in the past. Resident #1's Family Member D asked about getting labs. Nurse A stated I told her I would get them in the morning. Nurse A was asked if she notified the doctor of the resident passing large amounts of fluids which was a different symptom for him, she said she could not recall if she did notify the doctor but did not see any documentation in the resident's chart when she looked in Resident #1's electronic record. When asked about the medication error, she said Resident #1 should not have received the Losartan due to his blood pressure outside of the parameters. When asked why the resident was given the medication, she said I don't know. In an interview on [DATE] at 12:25 pm, Physician B said the facility did not contact her concerning Resident #1 on [DATE]. She said she should have been contacted due to the resident's change in condition of having large watery stools, which he did not have before, and for his low blood pressure. She would have ordered labs stat and would have sent the resident to the ER. She said she also was not notified of the medication error but did not think the medication error contributed to his death but could have been the reason his blood pressure was low on [DATE] when the nurse took it at 4:00 pm. She said it was her expectation for the facility to contact her for a resident's change in condition. In an interview on [DATE] at 1:00 pm, the DIT said she had not received any notification of Resident #1's medication error. She said Resident #1 normally had green loose stools. She said if Resident #1 had a large amount of watery stools that was different from his baseline, Nurse A should have contacted the physician about the resident's change in condition. In an interview on [DATE] at 1:10 pm, Resident #1's Family Member E said Nurse A should have taken action for the resident's change in condition. Family Member E said Family Member D texted on [DATE] around 4:00 pm and said that Resident #1 was breathing differently, he was not his normal self. Family Member E told Family Member D to go and get the nurse, and she did. She said she told the nurse that Resident #1 was breathing differently and was not himself, but Nurse A did not think so. Nurse A told Family Member D that Resident #1 had been gushing fluids in his ostomy bag today which was different for him. Resident #1's Family Member E told her to have the nurse take his blood pressure and it was 98/50 with a pulse 100. I texted her back and said it sounds like the same symptoms when he was in the hospital which was dehydration and low potassium. Resident #1's Family Member D told Nurse A that and said she would get labs in the morning. That was all that was done. Resident #1's Family Member E requested a copy of Resident #1's records from the facility and there was nothing reflecting in his notes that addressed his change in condition or that he was gushing fluids or that the doctor was notified of the medication error. The facility did not even give Resident #1 a fighting chance and send him to the ER. His change in condition was not addressed. In an interview on [DATE] at 3:34 pm, LVN C said she cared for Resident #1 on the evening of [DATE] and on the morning of [DATE] and initiated CPR when she found Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675593 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 675593 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wisteria Place 3202 S Willis St Abilene, TX 79605 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few #1 unresponsive. She said on that evening, [DATE], Resident #1 was at his baseline but was acting more tired than normal, and his ostomy bag had to be changed because it busted. She could not remember the reason the bag was busted but said he had trouble with the seal. She could not remember if Resident #1 was having watery stools in his ileostomy bag. She said she did not contact anyone about Resident #1 that evening prior to finding him on the floor. Record review of the facility policy Significant Change of Condition, Response, dated as revised 12/2023 revealed the following [in part]:Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care.Procedure: 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. 2. The nurse will perform and document an assessment of the resident and identify any additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider to obtain new orders or interventions. Record review of the facility policy Pharmacy Services: Medication Errors and Adverse Reactions, dated as revised 12/2019, revealed the following [in part]: Policy: It is the policy of the facility that medication errors and adverse drug reactions must be reported to the resident's attending physician.Procedures:1. Adverse drug reactions and medication errors with adverse clinical consequences must be reported to the resident's attending physician immediately. 5. The medical director, director of nursing services, and consultant pharmacist must be informed of all medication errors and adverse reactions.This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified and the IJ template was provided to the facility on [DATE] at 3:40 p.m. and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on [DATE] at 2:12 pm and included the following:PLAN OF REMOVAL, F580, [DATE]Underlying cause deficiency: The facility failed to notify MD and Resident #1's caregivers about change of condition whose records were reviewed for Resident's Rights. This deficient practice has the potential to affect all residents of the facility.1. Address how staff will accomplish corrective action for those residents found to have been affected by the deficiency1a. Review of all residents for any identified change of conditions by DON, Director of Nurses in Training (DIT), and ADON for change of condition completed [DATE]-and identified change of condition were documented with appropriate interventions* DON and Director of Nurses in Training (DIT) performed grand rounds of all residents going room to room with licensed nurses initiated on [DATE] and completed on [DATE]. Additionally, DON and DIT reviewed progress notes and change of condition documentation* No other residents were found to be affected after review on [DATE]. Address how staff will identify other residents who have the potential to be affected by the same deficiency 2a. Review of all residents for any identified change of conditions by DON, Director of Nurses in Training (DIT), and ADON for change of condition completed [DATE]-and identified change of condition were documented with appropriate interventions* DON and Director of Nurses in Training (DIT) performed grand rounds of all residents going room to room with licensed nurses initiated on [DATE] and completed on [DATE]. Additionally, DON and DIT reviewed progress notes and change of condition documentation* No other residents were found to be affected after review on [DATE]b. DON, DIT, or designee will review change of condition, hot rack charting, 24-hour summary report that includes progress notes, and all orders in the order listing report to ensure that residents aren't affected by this deficiency* This practice was initiated on [DATE] and will be monitored ongoing by DON or designee* Results will be reported in QAPI 3. Address the measures that will be put in place or the systemic changes that will be made to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675593 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 675593 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wisteria Place 3202 S Willis St Abilene, TX 79605 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few ensure that the deficiency will not recur 3a. Education initiated with all nursing staff on:* Change of condition and reporting & monitoring* Initiated today, [DATE] in person or via phone and was completed [DATE] at 10:00am* This was initiated by the DON and Director of Nursing in Training (DIT) and will be ongoing for new hires.3b. All licensed nursing staff will complete competency on change of condition* Initiated today and will be completed by [DATE] for all scheduled staff * DON and DIT will ensure competency is completed prior to shift and ongoing for new hires.3c. Staff will not be allowed to work unless they have completed the education and competency checks. This education will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and competency check. For those that do not pass the competency check, they will not be permitted to work until they are re-educated and pass the competency check. The DON and Operations Manager will verify that the competency and education have been completed by all new staff and current staff. 4. Indicate how the provider plans to monitor staff to ensure that solutions are sustained 4a. DON/ADON will ensure licensed nurses identify, and document all change of condition on the change of condition log and will not be removed until change of condition is resolved. This practice was initiated on [DATE] and will be ongoing. * DON and/or designee will be part of shift-to-shift report to help identify residents with change of condition, notification, and documentation 5. The actions the facility will take to ensure the violation will not reoccur5a. Nurse A received written counseling on [DATE] and Nurse A was educated on [DATE] on the following:* Change of condition* Resident rights* The rights of medication administration following orders for blood pressure parameters5b. Education initiated with all nursing staff on change of condition, identification, reporting, and documentation* Done [DATE] in person or via phone* This process was initiated [DATE] by DON, DIT, or designee and completed on [DATE].5c. All staff will complete competency on change of condition* Done [DATE] in person or via phone and or prior to shift.* This process was initiated and monitored by DON, DIT, or designee.6. Indicate when corrective action will be: initiated on [DATE] and will be ongoing6a. Interdisciplinary team (DON, Operations Manager, or Designee) are tracking notification of changes in condition, treatment, room assignment, or rights to ensure compliance with F5806b. Review tracking of change of condition as an interdisciplinary team (DON, Operations Manager, MDS, or designee) daily during clinical meeting6c. Interdisciplinary team (DON, ADON, MDS, Operations Manager, or designee) will review change of condition in standard of care (SOC) meeting weekly and report in QAPI monthly6d. Ad Hoc QAPI was completed [DATE] regarding IJ template with all interdisciplinary team members and medical director signatures.On [DATE] review of the Plan of Removal was initiated to confirm Immediate Jeopardy (IJ) could sufficiently be removed by:Verification of #1In an interview on [DATE] at 3:28 pm, the DON and DIT stated all residents had been reviewed. No other concerns identified. A record review on [DATE] at 4:06 pm revealed all residents were evaluated. Verification #22a: In an interview on [DATE] at 3:20 pm, the DON and DIT said all residents have been reviewed for change in condition including conducting ground rounds of all residents by going room and were completed on [DATE]. No other residents were found to be affective after review. 2b: In an interview on [DATE] at 3:30 pm, the DON and DIT said the process was initiated on [DATE] that includes daily reviewing change of condition documentation, charting in the electronic record, 24-hour summary report and physician orders. This process is being conducted by DON, DIT or designee. Results will be reported in QAPI meetings. A record review on [DATE] at 4:12 pm, revealed documentation completed for Order Listing Report and 24-hour summary communications, dated [DATE] and [DATE]. Verification #33a. In an interview on [DATE] at 3:32 pm, the DON and DIT said all nursing staff have completed in-services on change in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675593 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 675593 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wisteria Place 3202 S Willis St Abilene, TX 79605 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few condition and reporting and monitoring. In addition, all nurses have completed in-services on blood pressures and Resident Rights. In-services were initiated on [DATE] and were completed on [DATE]. In a record review on [DATE] at 4:15 pm documentation of in-services revealed, including staff sign-in sheets for

F580 Change in Condition and Resident rights for all staff including Nurses, CNAs and Physical Therapy. Nurses completed in-services on Administration Medications - being aware of blood pressure parameters and reporting errors. Nurses and CMAs. All staff have completed. 3b. In an interview on [DATE] at 3:33 pm, DON and DIT said all nursing staff have completed and passed the change in condition competency evaluations, except for a few PRN staff. Those staff will not be able to work until they have completed the evaluation. In a record review on [DATE] at 4:15 pm, the Change in Condition Competency Evaluations were reviewed. All PRN staff were identified. 3c. Interviews on [DATE] with the following nursing staff stated they had received training on Change in Condition, Resident Rights, Medication Administration/Errors and blood pressure parameters. All said they have completed a competency evaluation. 1. [DATE] at 2:20 pm, LVN F 2. [DATE] at 2:25 pm, LVN G 3. [DATE] at 2:30 pm, LVN H 4. [DATE] at 2:35 pm. ADON5. [DATE] at 2:45 pm, LVN I 6. [DATE] at 3:00 pm, LVN J 7. [DATE] at 3:30 pm, RN K8. [DATE] at 5:45 pm, LVN L9. [DATE] at 6:00 pm, RN M10. [DATE] at 6:15 pm, CMA NVerification of #4In an interview on [DATE] at 3:35 pm, the DON and DIT said how the facility plans to monitor staff to ensure that solutions are sustained is a condition report that is to be reviewed at every shift change and documentation logged. In a record review on [DATE] at 4:28 pm, the documentation Change in Condition report documentation was called Order [NAME] Report. Logged completed for [DATE] and [DATE]. Verification #55a: In an interview on [DATE] at 3:36 pm, the DON and DIT said Nurse A received education and counseling on change in condition, resident rights, and the rights of medication administration following orders for blood pressure parameters. In an record review on [DATE] at 4:29 pm, revealed documentation of Counseling/Disciplinary Notice for Nurse A. Completed and signed on [DATE]. 5b: In an interview on [DATE] at 3:37 pm, the DON and DIT said all staff have completed training on change in condition and resident rights except for a few PRN staff on [DATE]. Those staff will not be allowed to work until they have completed training. A record review on [DATE] at 4:15 pm, revealed documentation of in-service and signs in sheets for Change in Condition and Resident Rights were completed by all staff except for the identified PRN staff. 5c: Interview with staff on [DATE] verifying they had completed training on change in condition and resident rights.11. [DATE] at 2:22 pm, CNA O12. [DATE] 2:27 pm, CNA P13. [DATE] at 2:32 pm, CNA Q14. [DATE] at 2:37 pm, Housekeeping Supervisor. She also said all 5 of her staff have completed training. 15. [DATE] at 2:42 pm, Dietary Manager. She also said all of her kitchen staff have completed training. 16. [DATE] at 3:05 pm, Maintenance Manager.17. [DATE] at 3:10 pm, Director of Rehabilitation. She also said all of her staff have completed training. 18. [DATE] at 3:13 pm, Receptionist R19. [DATE] at 3:15 pm, CNA S20. [DATE] at 3:17 pm, Physical Therapist T21. [DATE] at 3:20 pm, Rehabilitation Student U22. [DATE] at 3:22 pm, Speech Therapist V23. [DATE] at 3:25 pm, Community Resident Liaison24. [DATE] at 3:30 pm, CNA W25. [DATE] at 5:47 pm, CNA X26. [DATE] at 5:50 pm, CNA Y27. [DATE] at 5:53 pm, CNA Z28. [DATE] at 5:56 pm, CNA AA29. [DATE] at 5:59 pm, CNA BB30. [DATE] at 6:03 pm, CNA CC31. [DATE] at 6:10 pm, CNA DDVerification #6In an interview on [DATE] at 3:39 pm, the DON and DIT said a change in condition log was implemented on [DATE] and is reviewed daily by the Interdisciplinary Team in the morning meeting and reviewed weekly in QAPI. In a record review on [DATE] at 4:34 pm, an ad hoc QAPI meeting was held on [DATE]. Sign in sheet revealed all required members attended. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675593 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 675593 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wisteria Place 3202 S Willis St Abilene, TX 79605 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 0580 with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675593 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 675593 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wisteria Place 3202 S Willis St Abilene, TX 79605 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 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 interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents (Resident #1) reviewed for medication errors in that: RN A gave Resident #1's blood pressure medication Losartan Potassium 25 mg needed for hypertension, outside of the ordered parameters. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medication by receiving too much or not enough. Findings Included: Record review of a Comprehensive assessment dated [DATE] revealed Resident #1 was an [AGE] year-old male, admitted to the facility on [DATE] and expired on [DATE]. He had a primary diagnosis of [NAME] Syndrome (paralysis of colon - colon acts like it is blocked but nothing is blocking it). Additional diagnoses included ileostomy status (stoma of the small intestine), hypokalemia (low potassium in blood serum), atherosclerotic heart disease of native coronary artery without angina pectoris (the arteries supplying blood to the heart become narrowed due to the accumulation of plaque), congestive heart failure (the heart's ability to pump blood well). The resident had a BIMS score of 03 (severe cognitive impairment). Record review on [DATE] of Resident #1's Physician's Order Summary Report, dated for active orders as of [DATE], revealed an order for Losartan Potassium 25 MG Tablet, Give 1 tablet by mouth one time a day for Hypertension, HOLD IF SBP IS LESS THAN 120 OR DBP LESS THAN 70. Start date of [DATE]. A record review on [DATE] of Resident #1 Medication Administration Record revealed the resident received losartan potassium 25 mg for hypertension on [DATE] at 7:00 am. The physician order instructed to hold medication if systolic blood pressure is less than 120 and diastolic blood pressure is less than 70. Resident's #1 recorded blood pressure at the time of medication administration was 110/76 with a pulse of 100. The medication was given outside of the parameters. Nurse A failed to notify the DON and Physician of a medication error. In an interview with Resident #1's Family Member D on [DATE] at 11:40 am, said they visited Resident #1 every day. On [DATE] at 4:00 pm Family Member D visited Resident #1 and noticed he was breathing differently, looked pale and was weaker. Family Member D went and got Nurse A and expressed their concerns. Family Member D requested Resident #1's vitals be taken. Nurse A took Resident #1's vitals which revealed a blood pressure of 98/50 with a pulse of 100. Nurse A said his blood pressure was low but not critical. A record review of Resident #1's blood pressures revealed on [DATE] at 10:19 pm, Resident #1's blood pressure was 95/62 with a pulse of 100. In an interview with Nurse A on [DATE] at 11:55 am, she said Resident #1's Family Member D came and got her stating Resident #1's breathing was different, and he didn't look good and requested his vitals be taken. She said she took his vital signs but could not remember them exactly, but his vitals were low but not extremely low. Nurse A said did not see that his breathing was different, it was not labored, and he was talking to me and did not express any complaints. When asked about the medication error, she said Resident #1 should not have received the Losartan due to his blood pressure outside of the parameters. When asked why the resident was given the medication, she said I don't know. In an interview with Physician B on [DATE] at 12:25 pm, she said the facility did not contact her concerning Resident #1 on [DATE]. She said she should have been contacted due to the resident's low blood pressure. She also said she was not notified of the medication error but did not think the medication error contributed to his death but could have been the reason his blood pressure was low on [DATE] when the nurse took it at 4:00 pm. In an interview with the DIT on [DATE] at 1:00 pm, she said she had not received any notification of Resident #1's medication error. She said a potential negative outcome of receiving blood pressure medications outside of the parameters would be the resident's blood pressure could bottom out. Record review of the facility policy Pharmacy Services: Medication Errors and Adverse Reactions, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675593 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 675593 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wisteria Place 3202 S Willis St Abilene, TX 79605 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete dated as revised 12/2019, revealed the following [in part]: Policy: It is the policy of the facility that medication errors and adverse drug reactions must be reported to the resident's attending physician.Procedures:1. Adverse drug reactions and medication errors with adverse clinical consequences must be reported to the resident's attending physician immediately. 5. The medical director, director of nursing services, and consultant pharmacist must be informed of all medication errors and adverse reactions. Event ID: Facility ID: 675593 If continuation sheet Page 8 of 8