Health inspection·November 4, 2025

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, observation, and record review, the facility failed to ensure that residents were free of significant medication errors for 6 of 10 residents (Resident #1, 2, 3, 5, 6, and 7) reviewed for pharmacy services. The facility failed to administer: Resident #1's order for Hydralazine and Amlodipine for blood pressure. Resident #2's order for Lamotrigine and Levetiracetam for seizures. Resident #3's order for Carvedilol for blood pressure, Entresto for heart failure, Torsemide for edema, and screen her blood pressure. Resident #5 order for Ziprasidone for Schizophrenia, Resident #6's order for Carvedilol for atrial fibrillation and congestive heart failure, Eliquis for heart failure, Levetiracetam for seizures, Lisinopril for high blood pressure, Vimpat for epilepsy, and screened for blood pressure. Resident #7's order for Midodrine for her blood pressure, Levetiracetam for convulsions, and screened for blood pressure. This failure could place residents at risk of complications, as well as jeopardizing their health and safety. Findings included:-Record review of Resident #1's admission Record dated 11/04/25 indicated her initial admission was 03/21/25 and was readmitted [DATE]. Record review of Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Brief Interview for Mental Status score (BIMS) was not filled out because resident rarely or never understood. Record review of Resident #1's Care Plan dated 09/05/25 included a focus area for hypertension, initiated 03/24/25 and revised 04/07/25, with interventions to educate the caregiver on the importance of medication, administer hypertensive (blood pressure consistently remains above normal levels) medications as order, monitor side effects such as orthostatic hypotension (a condition where blood pressure drops significantly upon standing up from a sitting or lying position), monitor tachycardia (increased heart rate exceeding 100 beats per minute), monitor the medications effectiveness, monitor/document/report to physician (MD) as needed any signs/symptoms (s/sx) of malignant hypertension to include headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, and difficulty breathing. Record review of Resident #1's Order Summary Report dated 11/04/25 with active orders as of 10/01/25, revealed a [AGE] year-old female with diagnoses that included essential-primary hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying medical cause). The order was to administer: *Hydralazine HCI (hydrochloride) oral tablet, 25 milligrams (mg.), start date 03/07/25, give via G-tube (gastrostomy tube) every 6 hours as needed for elevated blood pressure (BP) related to hypertension, and systolic blood pressure ((SBP) indicates a significantly elevated risk for heart disease, stroke, and other cardiovascular issues) more than 160. *Amlodipine Besylate oral tablet 10 mg., start dated 03/08/25, give 10 mg. via G-Tube one time a day related to essential (primary) hypertension hold for SBP less than 110 or HR less than 60 Record review of Resident #1's Treatment Administration Record (TAR) dated 11/04/25 that covered the dates 10/01/25 through 10/31/25 revealed the A.M. (morning or ante meridiem before midday) 10/29/25, entries were blank, indicting her blood pressure was not taken and recorded. And further review of the Residents Affected - Some Page 1 of 8 676028 676028 11/04/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some TAR indicated her Amlodipine Besylate and Hydralazine HCI were not administered on 10/29/25. Observation and an attempted interview on 11/03/25 at 4:50 P.M. revealed Resident #1, who was lying in her bed, had a trachea (a cartilaginous tube that connects the larynx to the lung's bronchi, enabling air passage) and a tube feeding (delivers liquid nutrition through a flexi tube that goes in through your nose or directly into your stomach or small intestine) attachments. Resident #1 nodded her head up and down to all the questions asked of her, she was unable to respond appropriately. During an interview on 10/31/25 at 6:40 P.M with Licensed Vocation Nurse (LVN D) indicated she worked on 10/29/25 and left shift at approximately 7:30 A.M after the Administrator directed her to leave at 7:49 A.M. because he was taking over her residents, that included Resident #1. During an interview on 11/03/25 at 9:54 A.M. with LVN B indicated the morning medications are administered between 6 A.M. and 8 A.M. LVN B said on 10/29/25 at 7 A.M. she witnessed the Administrator and ADON at the facility. Then at approximately 10:45 A.M. she received red alerts on her electronic medication administration record, revealing resident #1, had not received her morning medications. LVN B said she was approached by the DON at 11 A.M. and she informed him Resident #1 had not received her morning medications. Afterwards, LVN B said she witnessed ADON asking LVN C to administer Residents #1's medication; however, she explained that she could not administer her morning medications because it was too close to the next medication pass. LVN B said the nurse assigned to Hall 100, which included Residents #1, failed to show up to work at 6 A.M. and a replacement was not assigned to resident #1. During an interview on 11/04/25 at 1:00 P.M. with the Administrator, indicated on 10/29/25 at 7:45 A.M. he witnessed the night nurse, LVN D, on duty because the day nurse failed to show up for her shift at 6 AM. The Administrator, who is an LVN, took over LVN D's position so she could leave her night shift, which included caring for resident #1. The Administrator said in Hall 100 he completed resident's blood sugar test and then was informed by ADON that LVN C would take over the residents on Hall 100, which included Resident #1. The Administrator said he could not recall what time he left the residents he was caring for in Hall 100, including Resident #1; however, he confirmed the medications were not administered to Resident #1 because nobody did it. The Administrator said this During an interview on 11/04/25 at 1 P.M. with LVN C indicated on 10/29/25 at 9:00 A.M. she started her shift and was not informed that she was the charge nurse for Residents #1. LVN C said it was not until 11:30 A.M. that she checked her office emails and discovered an email from ADON, directing her to take over the residents because the Administrator and DON, who were in the building, were in training. LVN C said at approximately 11:30 am she met with the ADON and obtained the medication cart keys from her and informed her it was too late to administer the morning medications, because it was almost noon. LVN C said she did not call the physician or the family to inform them of the medication errors for resident #1, because she was only Resident #1's charge nurse for approximately 45 minutes, before she had to conduct rounds with the wound care physician. During an interview on 11/03/25 at 12:01 P.M. LVN E indicated she was working on 10/29/25 from 6 A.M. to 6 P.M. and there was not a nurse assigned to Resident #1, until 11:30 P.M. That's when LVN E said she heard LVN C informed the ADON that it was too late to give the 6:00 A.M. medications but would administer Resident #1's noon medications. During an interview on 11/03/25 at 2:04 P.M. with Medication Aide (MA F) indicated she worked Hall 100 hall that included Resident #1; however, her medications must be administered by a nurse via G-tube. MA F said on 10/29/25 at after 6 A.M., she was passing the morning medications to her Residents, when she noticed Residents #1, had not received her medications, because there was not a nurse on duty to administer her medications. During an interview on 11/04/25 at 3:48 P.M. with the Director of Nurses 676028 Page 2 of 8 676028 11/04/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (DON), indicated on 10/31/25 he became aware that Resident #1, was not administered for her medications on 10/29/25 during the 6 A.M. medication pass. The DON said he assessed Resident #1, who did not have a negative outcome due to missing her medications. During an interview on 11/04/25 at 2:48 P.M., Nurse Practitioner (NP-A) indicated her concern would be Resident #1's Amlodipine Besylate and/or Hydralazine HCI not being administered on 10/29/25 because it could increase her blood pressure and potentially lead to a stroke. -Record review of Resident #2's admission Record dated 11/04/25 indicated her initial admission was 08/01/22 and was readmitted [DATE]. Record review of Resident #2's Quarterly MDS assessment dated [DATE], revealed her BIMS score was a 7 indicating severe cognitive status. Record review of Resident #2's Care Plan dated 09/10/25 included a focus area for seizure disorder initiated 10/15/22 with an intervention to give seizure medications as order by her physician. Record review of Resident #2's Order Summary Report dated 11/04/25 with active orders as of 10/01/25, revealed a [AGE] year-old female with diagnoses that included other seizures (different types of seizures beyond the most common ones, including various generalized seizures like absence, atonic-complete loss of muscle and myoclonic seizures-brief involuntary muscle jerks, and focal seizures which start in one part of the brain). The order was to administer: * Lamotrigine oral tablet 25 mg., start dated 03/08/25, during the A.M., give 2 tablets via G-tube two times a day for seizures.*Levetiracetam oral tablet 500 mg., start date 02/19/25, during the A.M., give 1 table via G-tube two times a day for seizures. Review of Resident #2's TAR dated 11/04/25 that covered the dates 10/01/25 through 10/31/25 revealed on 10/29/25 the A.M. entries were blank, indicating Resident #2 did not receive her Lamotrigine and Levetiracetam. Observation and interview on 11/04/25 at 11:33 A.M. revealed Resident #2, who was lying in her bed, had a trachea and tube feeding attachments. Resident #2 indicated she couldn't recall when she received her medications. During an interview on 10/31/25 at 6:40 P.M with LVN D indicated she worked on 10/29/25 and left shift at approximately 7:30 A.M after the Administrator directed her to leave at 7:49 A.M. because he was taking over her residents, that included Resident #2. During an interview on 11/03/25 at 9:54 A.M. with LVN B indicated the morning medications are administered between 6 A.M. and 8 A.M. LVN B said on 10/29/25 at 7 A.M. she witnessed the Administrator and ADON at the facility. Then at approximately 10:45 A.M. she received red alerts on her electronic medication administration record, revealing resident #2, had not received her morning medications. LVN B said she was approached by the DON at 11 A.M. and she informed him Resident #2 had not received her morning medications. Afterwards, LVN B said she witnessed ADON asking LVN C to administer Residents #2's medication; however, she explained that she could not administer her morning medications because it was too close to the next medication pass. LVN B said the nurse assigned to Hall 100, which included Residents #2, failed to show up to work at 6 A.M. and a replacement was not assigned to resident #2. During an interview on 11/04/25 at 1:00 P.M. with the Administrator, indicated on 10/29/25 at 7:45 A.M. he witnessed the night nurse, LVN D, on duty because the day nurse failed to show up for her shift at 6 AM. The Administrator, who is an LVN, took over LVN D's position so she could leave her night shift, which included caring for resident #2. The Administrator said in Hall 100 he completed resident's blood sugar test and then was informed by ADON that LVN C would take over the residents on Hall 100, which included Resident #2. The Administrator said he could not recall what time he left the residents he was caring for in Hall 100, including Resident #2; however, he confirmed the medications were not administered to Resident #2 because nobody did it. The Administrator said this During an interview on 11/04/25 at 1 P.M. with LVN C indicated on 10/29/25 at 9:00 A.M. she started her shift and was not informed that she was the charge nurse for Residents #2. 676028 Page 3 of 8 676028 11/04/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LVN C said it was not until 11:30 A.M. that she checked her office emails and discovered an email from ADON, directing her to take over the residents because the Administrator and DON, who were in the building, were in training. LVN C said at approximately 11:30 am she met with the ADON and obtained the medication cart keys from her and informed her it was too late to administer the morning medications, because it was almost noon. LVN C said she did not call the physician or the family to inform them of the medication errors for resident #2, because she was only Resident #2's charge nurse for approximately 45 minutes, before she had to conduct rounds with the wound care physician. During an interview on 11/03/25 at 12:01 P.M. LVN E indicated she was working on 10/29/25 from 6 A.M. to 6 P.M. and there was not a nurse assigned to Resident #2, until 11:30 P.M. That's when LVN E said she heard LVN C informed the ADON that it was too late to give the 6:00 A.M. medications but would administer Resident #2's noon medications. During an interview on 11/03/25 at 2:04 P.M. with MA F indicated she has worked Hall 100 hall that included Resident #2; however, her medications must be administered by a nurse via G-tube. MA F said on 10/29/25 at after 6 A.M., she was passing the morning medications to her Residents, when she noticed Residents #2, had not received her medications, because there was not a nurse on duty to administer her medications. During an interview on 11/04/25 at 3:48 P.M. with the DON, indicated on 10/31/25 he became aware that Resident #2, was not administered for her medications on 10/29/25 during the 6 A.M. medication pass. The DON said the risk of not administering resident their scheduled medications could increase their risk of seizure activity, increase their blood pressure, lower their blood pressure, depending on what medication was not administered. The DON said he assessed Resident #2, who did not have a negative outcome due to missing her medications. During an interview on 11/04/25 at 2:51 P.M., NP-A indicated her concern with Resident #2 not being administered her AM 10/29/25 medications, would be her Lamotrigine and Levetiracetam, which could have led to a seizure. -Record review of Resident #3's admission Record dated 11/04/25 indicated her initial admission was 05/18/22 and was readmitted [DATE]. Record review of Resident #3's Quarterly MDS assessment dated [DATE], revealed her Brief Interview for Mental Status score was a 7 indicating severe cognitive status. Record review of Resident #3's Care Plan dated 09/02/25 included the following focus areas: *Pacemaker that was initiated 07/13/22 and updated 02/22/23 with interventions to educate the caregiver on the importance of medication; give anti-hypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increase heart rate (Tachycardia) and effectiveness.*Hypertension with hyperlipidemia initiated on 07/13/22 and updated 02/22/23 with interventions to educate the caregiver on the importance of medication; give anti-hypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increase heart rate (Tachycardia) and effectiveness. -Record review of Resident #3's Order Summary Report dated 11/04/25 with active orders as of 10/01/25, revealed a [AGE] year-old female with diagnoses that included hypotension (a condition in which the force of blood against the artery wall is consistently too high), cardiac arrest (occurs when the heart suddenly stops beating, preventing bold from circulating throughout the body, Thrombocytopenia ( a condition characterized by a low platelet count in the blood), chronic combined systolic and diastolic heart failure (a condition where the heart muscle is weakened (systolic dysfunction) and/or stiffened (diastolic dysfunction) simultaneously, leading to impaired pumping ability, and essential-primary hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying medical cause). The order was to administer: *Carvedilol Tablet 6.25 mg. via G-tube, start dated 01/19/24, two times a day related to essential primary hypertension, hold for SBP less than 100, DBP less than 60, HR less than 55. *Entresto (Sacubitril-Valsartan) oral tablet 24-26 mg., start date 04/05/25, give 1 tablet via G-tube two 676028 Page 4 of 8 676028 11/04/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some times a day related to chronic combined systolic (congestive) and diastolic (congestive) heart failure; and *Torsemide oral tablet 10 mg., start date 01/19/25, give 20 mg via G-tube one time a day for edema, give 2 tables to equal 20 mg dosage. Review of Resident #3's TAR dated 11/04/25 that covered the dates 10/01/25 through 10/31/25 revealed the morning entries on 10/29/25 were blank, indicting her blood pressure was not taken and recorded, and she was not administered her Carvedilol, Entresto, and Torsemide. Observation and interview on 11/03/25 at 11:37 A.M. revealed Resident #3, who was lying in her bed, had a trachea and tube feeding attachments. Resident #3, who nodded her head up and down (indicating a yes response), and side to side (indicating a no response) to questions asked of her, indicated she had could not recall when she received her medications. During an interview on 10/31/25 at 6:40 P.M with LVN D indicated she worked on 10/29/25 and left shift at approximately 7:30 A.M after the Administrator directed her to leave at 7:49 A.M. because he was taking over her residents, that included Resident #1. During an interview on 11/03/25 at 9:54 A.M. with LVN B indicated the morning medications are administered between 6 A.M. and 8 A.M. LVN B said on 10/29/25 at 7 A.M. she witnessed the Administrator and ADON at the facility. Then at approximately 10:45 A.M. she received red alerts on her electronic medication administration record, revealing resident #3, and had not received her morning medications. LVN B said she was approached by the DON at 11 A.M. and she informed him Resident #3 had not received her morning medications. Afterwards, LVN B said she witnessed ADON asking LVN C to administer Residents #3's medication; however, she explained that she could not administer her morning medications because it was too close to the next medication pass. LVN B said the nurse assigned to Hall 100, which included Residents #3, failed to show up to work at 6 A.M. and a replacement was not assigned to resident #3. During an interview on 11/04/25 at 1:00 P.M. with the Administrator, indicated on 10/29/25 at 7:45 A.M. he witnessed the night nurse, LVN D, on duty because the day nurse failed to show up for her shift at 6 AM. The Administrator, who is an LVN, took over LVN D's position so she could leave her night shift, which included caring for resident #3. The Administrator said in Hall 100 he completed resident's blood sugar test and then was informed by ADON that LVN C would take over the residents on Hall 100, which included Resident #3. The Administrator said he could not recall what time he left the residents he was caring for in Hall 100, including Resident #3; however, he confirmed the medications were not administered to Resident #3 because nobody did it. The Administrator said this medication errors were not at 1 P.M. with LVN C indicated on 10/29/25 at 9:00 A.M. she started her shift and was not informed that she was the charge nurse for Residents #3. LVN C said it was not until 11:30 A.M. that she checked her office emails and discovered an email from ADON, directing her to take over the residents because the Administrator and DON, who were in the building, were in training. LVN C said at approximately 11:30 am she met with the ADON and obtained the medication cart keys from her and informed her it was too late to administer the morning medications, because it was almost noon. LVN C said she did not call the physician or the family to inform them of the medication errors for resident #3, because she was only Resident #3's charge nurse for approximately 45 minutes, before she had to conduct rounds with the wound care physician. During an interview on 11/03/25 at 12:01 P.M. LVN E indicated she was working on 10/29/25 from 6 A.M. to 6 P.M. and there was not a nurse assigned to Resident #3, until 11:30 P.M. That's when LVN E said she heard LVN C informed the ADON that it was too late to give the 6:00 A.M. medications but would administer Resident #3's noon medications. During an interview on 11/03/25 at 2:04 P.M. with MA F indicated she has worked Hall 100 hall that included Resident #3; however, her medications must be administered by a nurse via G-tube. MA F said on 10/29/25 at after 6 A.M., she was 676028 Page 5 of 8 676028 11/04/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some passing the morning medications to her Residents, when she noticed Residents #3, had not received her medications, because there was not a nurse on duty to administer her medications. During an interview on 11/04/25 at 3:48 P.M. with the DON, indicated on 10/31/25 he became aware that Resident #3, was not administered for her medications on 10/29/25 during the 6 A.M. medication pass. The DON said the risk of not administering resident their scheduled medications could increase their risk of seizure activity, increase their blood pressure, lower their blood pressure, depending on what medication was not administered. The DON said he assessed Resident #3, who did not have a negative outcome due to missing her medications. During an interview on 11/04/25 at 2:55 P.M., NP-A indicated her concern with Resident #3 not being administered her AM 10/29/25 medications, would be her Torsemide, Entresto, and Carvedilol due to a potential for heart failure. -Record review of Resident #5's admission Record dated 11/04/25 indicated her initial admission was 08/23/23 and was readmitted [DATE]. Record review of Resident #5's Quarterly MDS assessment dated [DATE], revealed her BIMS score was a 6 indicating severe cognitive status. Record review of Resident #5's Care Plan dated 09/11/25 the focus area for anti-psychotic medications initiated 09/12/23 due to diagnosis of schizophrenia with interventions to administer medications as ordered, and to discuss with physician and family the ongoing need for the use of these medications. Record review of Resident #5's Order Summary Report dated 11/04/25 with active orders as of 10/01/25, revealed a [AGE] year-old female with diagnoses that included recurrent severe without psychotic features, Schizophrenia. The order was to administer: *Ziprasidone HCl oral capsule 80 mg., started 10/16/23, give 1 capsule via G-tube one time a day related to Schizophrenia, unspecified. Record review of Resident #5's TAR dated 11/04/25 that covered the dates 10/01/25 through 10/31/25 revealed the A.M. 10/29/25 entry was blank, indicating Ziprasidone was not administered. Observation and interview on 11/03/25 at 5:00 P.M. revealed Resident #5, who was lying in her bed, had a trachea and tube feeding attachments. Resident #5 indicated she could not recall if she had been administered her medication. During an interview on 10/31/25 at 6:40 P.M with LVN D indicated she worked on 10/29/25 and left shift at approximately 7:30 A.M after the Administrator directed her to leave at 7:49 A.M. because he was taking over her residents, that included Resident #5. During an interview on 11/03/25 at 9:54 A.M. with LVN B indicated the morning medications are administered between 6 A.M. and 8 A.M. LVN B said on 10/29/25 at 7 A.M. she witnessed the Administrator and ADON at the facility. Then at approximately 10:45 A.M. she received red alerts on her electronic medication administration record, revealing resident #5, had not received her morning medications. LVN B said she was approached by the DON at 11 A.M. and she informed him Resident #5 had not received her morning medications. Afterwards, LVN B said she witnessed ADON asking LVN C to administer Residents #5's medication; however, she explained that she could not administer her morning medications because it was too close to the next medication pass. LVN B said the nurse assigned to Hall 100, which included Residents #5, failed to show up to work at 6 A.M. and a replacement was not assigned to resident #5. During an interview on 11/04/25 at 1:00 P.M. with the Administrator, indicated on 10/29/25 at 7:45 A.M. he witnessed the night nurse, LVN D, on duty because the day nurse failed to show up for her shift at 6 AM. The Administrator, who is an LVN, took over LVN D's position so she could leave her night shift, which included caring for resident #5. The Administrator said in Hall 100 he completed resident's blood sugar test and then was informed by ADON that LVN C would take over the residents on Hall 100, which included Resident #5. The Administrator said he could not recall what time he left the residents he was caring for in Hall 100, including Resident #5; however, he confirmed the medications were not administered to Resident #5 because nobody did it. The Administrator said this medication errors were not 676028 Page 6 of 8 676028 11/04/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some investigation. During an interview on 11/04/25 at 1 P.M. with LVN C indicated on 10/29/25 at 9:00 A.M. she started her shift and was not informed that she was the charge nurse for Residents #5. LVN C said it was not until 11:30 A.M. that she checked her office emails and discovered an email from ADON, directing her to take over the residents because the Administrator and DON, who were in the building, were in training. LVN C said at approximately 11:30 am she met with the ADON and obtained the medication cart keys from her and informed her it was too late to administer the morning medications, because it was almost noon. LVN C said she did not call the physician or the family to inform them of the medication errors for resident #5, because she was only Resident #5's charge nurse for approximately 45 minutes, before she had to conduct rounds with the wound care physician. During an interview on 11/03/25 at 12:01 P.M. LVN E indicated she was working on 10/29/25 from 6 A.M. to 6 P.M. and there was not a nurse assigned to Resident #5, until 11:30 P.M. That's when LVN E said she heard LVN C informed the ADON that it was too late to give the 6:00 A.M. medications but would administer Resident #5's noon medications. During an interview on 11/03/25 at 2:04 P.M. with MA F indicated she has worked Hall 100 hall that included Resident #5; however, her medications must be administered by a nurse via G-tube. MA F said on 10/29/25 at after 6 A.M., she was passing the morning medications to her Residents, when she noticed Residents #5, had not received her medications, because there was not a nurse on duty to administer her medications. During an interview on 11/04/25 at 3:48 P.M. with the DON, indicated on 10/31/25 he became aware that Resident #5, was not administered for her medications on 10/29/25 during the 6 A.M. medication pass. The DON said the risk of not administering resident their scheduled medications could increase their risk of seizure activity, increase their blood pressure, lower their blood pressure, depending on what medication was not administered. The DON said he assessed Resident #5, who did not have a negative outcome due to missing her medications. During an interview on 11/04/25 at 3:03 P.M., NP-A indicated the concern she would have with Resident #5 not being administered her medications on 10/29/25, would be her Ziprasidone, because she has a diagnosis of Schizophrenia that could increase hallucinations. -Record review of Resident #6's admission Record dated 11/04/25 indicated her initial admission was 12/07/22 and was readmitted [DATE]. Record review of Resident #6's Quarterly MDS assessment dated [DATE], revealed her BIMS score was not filled out because resident rarely or never understood. Record review of Resident #6's Care Plan dated 09/08/25 included the focus area of congestive heart failure that was initiated 12/08/22 and revised on 03/02/23 with interventions to give cardiac medications as ordered. And the focus area for seizure disorder with interventions initiated 12/08/22 and revised 03/02/23 with interventions to give seizure medications as ordered. Record review of Resident #6's Order Summary Report dated 11/04/25 with active orders as of 10/01/25, revealed a [AGE] year-old female with diagnoses that included heart failure, Atherosclerotic heart disease of native coronary artery without angina pectoris, and hypertension. The order was to administer: * Carvedilol Tablet 12.5 mg., start dated 06/11/25, give 12.5 mg. via G-tube two times a day for atrial fibrillation and congestive heart failure related to paroxysmal atrial fibrillation (I48.0) hold if systolic is less than 100, hold if diastolic is less than 60, hold if pulse is less than 55. * Eliquis oral tablet 5 mg., (Apixaban), start dated 06/11/25, give 5 mg. via Peg-tube two times a day for secretions related to heart failure, unspecified, paroxysmal atrial fibrillation. * Levetiracetam tablet 500 mg., start dated 06/11/25, give 500 mg via G-tube two times a day for seizure.* Lisinopril tablet 2.5 mg., start dated 06/11/25, give 2.5 mg. via G-tube one time a day for hypertension related to essential (primary), hypertension (110) hold for SBP less than 100, DBP less than 60. * Vimpat tablet 100 mg. (Lacosamide), start dated 08/24/25, give 10 ml via G-tube two times a day for seizure related to epilepsy, unspecified, not intractable, 676028 Page 7 of 8 676028 11/04/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some without status epilepticus (prolonged seizure). *Midodrine HCl Tablet 5 mg., give 5 mg via G-Tube every 8 hours as needed for hypotension related to orthostatic hypotension, hold for SBP greater than 130, and DBP greater than 60. Record review of Resident #6's TAR dated 11/04/25 that covered the dates 10/01/25 through 10/31/25 revealed on 10/29/25 the following entries were blank, indicting her blood pressure was not taken and recorded, and she was not administered her Eliquis, Levetiracetam, Lisinopril, Vimpat, and her Midodrine. Observation and interview on 11/03/25 at 5:08 P.M. with Resident #6, who was lying in her bed, had a trachea and tube feeding attachments. Resident #6 did not respond to questions asked of her. During an interview on 10/31/25 at 6:40 P.M with LVN D indicated she worked on 10/29/25 and left shift at approximately 7:30 A.M after the Administrator directed her to leave at 7:49 A.M. because he was taking over her residents, that included Resident #6. During an interview on 11/03/25 at 9:54 A.M. with LVN B indicated the morning medications are administered between 6 A.M. and 8 A.M. LVN B said on 10/29/25 at 7 A.M. she witnessed the Administrator and ADON at the facility. Then at approximately 10:45 A.M. she received red alerts on her electronic medication administration record, revealing resident #6, had not received her morning medications. LVN B said she was approached by the DON at 11 A.M. and she informed him Resident #6 had not received her morning medications. Afterwards, LVN B said she witnessed ADON asking LVN C to administer Residents #6's medication; however, she explained that she could not administer her morning medications because it was too close to the next medication pass. LVN B said the nurse assigned to Hall 100, which included Residents #6, failed to show up to work at 6 A.M. and a replacement was not assigned to resident #6. During an interview on 11/04/25 at 1:00 P.M. with the Administrator, indicated on 10/29/25 at 7:45 A.M. he witnessed the night nurse, LVN D, on duty because the day nurse failed to show up for her shift at 6 AM. The Administrator, who is an LVN, took over LVN D's position so she could leave her night shift, which included caring for resident #6. The Administrator said in Hall 100 he completed resident's blood sugar test and then was informed by ADON that LVN C would take over the residents on Hall 100, which included Resident #6. The Administrator said he could not recall what time he left the residents he was caring for in Hall 100, including Resident #6; however, he confirmed the medications were not administered to Resident #6 because nobody did it. The Administrator said this During an interview on 11/04/25 a 676028 Page 8 of 8