Health inspection·April 24, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a change in residents health status for 2 of 46 residents (Residents #6 & # 25) reviewed for notification of changes. This failure could affect all Residents by causing their physicians, and representatives to be unaware of changes in a Resident's condition. Finding include: Record review of Resident #6's undated face sheet revealed a [AGE] year-old male. Resident #6 was originally admitted on [DATE] with the following diagnosis: hyperlipidemia (elevated lipids in the blood), cerebral infarction (disrupted blood flow to the brain), protein-calorie malnutrition, and neuropathic bladder (lack of bladder control). Record review of Resident #6's annual MDS dated [DATE], Section C- Cognitive patterns revealed he had a BIMS score of 15 which indicated resident is cognitively intact. Record review of physician orders for Resident #6 revealed active orders for atorvastatin 20 mg tablet (ATORVASTATIN CALCIUM) 1 tablet by mouth at bedtime, scheduled for 7pm. (lower bad cholesterol levels) clopidogrel 75 mg tablet (CLOPIDOGREL BISULFATE) 1 tablet by mouth 1 time per day, scheduled for 7pm.( a platelet inhibitor) mirtazapine 7.5 mg tablet (MIRTAZAPINE) 1 tablet by mouth at bedtime, scheduled for 7pm. (treat depression) tamsulosin 0.4 mg capsule (TAMSULOSIN HCL) 0.4mg capsule by mouth 1 time per day scheduled for 7pm. ( treat the symptoms of an enlarged prostate) thiamine HCl (vitamin B1) 100 mg tablet (THIAMINE HCL) 1 tablet by mouth 1 time per day, scheduled for 7pm. (Thiamine is required by our bodies to properly use carbohydrates) Record review of Resident #6's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: Page 1 of 31 676105 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0580 atorvastatin 20 mg tablet (ATORVASTATIN CALCIUM) 1 tablet by mouth at bedtime, scheduled for 7pm. Level of Harm - Minimal harm or potential for actual harm clopidogrel 75 mg tablet (CLOPIDOGREL BISULFATE) 1 tablet by mouth 1 time per day, scheduled for 7pm. Residents Affected - Few mirtazapine 7.5 mg tablet (MIRTAZAPINE) 1 tablet by mouth at bedtime, scheduled for 7pm. tamsulosin 0.4 mg capsule (TAMSULOSIN HCL) 0.4mg capsule by mouth 1 time per day scheduled for 7pm. thiamine HCl (vitamin B1) 100 mg tablet (THIAMINE HCL) 1 tablet by mouth 1 time per day, scheduled for 7pm. Record review of Resident #6's nurses note dated 4/12/2024 revealed Late entry Head to toe assessment to NP to let her know about the Xarelto given and then Plavix held. and she said resumed Plavix tmrw. Record review of Resident #6's vital sign sheet dated 4/12/2024 at 9:35 pm revealed a BP of 135/72, pulse of 68, respiratory rate of 20, temperature of 97.6 and oxygen saturation of 95. Record review of Resident #25's undated face sheet revealed an [AGE] year-old male. Resident #25 was originally admitted to the facility on [DATE] with the following diagnosis: atherosclerosis (plaque buildup in arteries), and insomnia. Record review of Resident #25's quarterly MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 12 which indicates resident was cognitively intact. Record review of physician orders for Resident #25 revealed active orders for melatonin 3 mg tablet (MELATONIN) 1 tablet by mouth daily at bedtime, scheduled for 8pm. (to help sleep) atorvastatin 80 mg tablet (ATORVASTATIN CALCIUM) 1 tablet by mouth at bedtime, scheduled for 8pm. (used to lower lipids known as cholesterol and triglycerides in the blood ) Record review of Resident #25's medication administration record dated 4/12/2024 revealed the following undocumented medication for 8 pm: melatonin 3 mg tablet (MELATONIN) 1 tablet by mouth daily at bedtime, scheduled for 8pm. atorvastatin 80 mg tablet (ATORVASTATIN CALCIUM) 1 tablet by mouth at bedtime, scheduled for 8pm. Record review of Resident #25's nurse note dated 4/12/2024 revealed Resident's head to toe assessment completed and within normal limits for resident. VS were within normal limits for resident. Resident was LVN A 04/23/2024 04:45 PM. No documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #25's vital signs sheet dated 4/12/2024 revealed a blood pressure of 131/64, pulse 63, respirations 18, temperature 97.9 and O2 saturations 96. 676105 Page 2 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 04/24/2024 at 9:30 AM, the Administrator stated once she became aware on 04/23/2024 that medications had been given early to residents on 04/12/2024 she started an investigation on 04/23/2024, and she identified there were 46 residents that could have received medications at a time other than ordered on 04/12/2024. She stated that she was not aware that notifications were not made on 04/12/2024 to the physicians and family members. She stated she discovered during her investigation on 04/23/2024 that a few notifications were made, but not all notifications were made on 04/12/2024. She stated that once she became aware of the situation and number of residents involved, all notifications were made to the physician, NP's, residents, and families on 04/23/2024. During an investigation on 04/24/2024 at 9:45 AM, the Corporate RN stated the DON had notified him on 04/12/2024 that there was a concern that one resident might have received his methadone early, and that two other residents might have had their medications switched and they could have taken the wrong medication and a few other residents could have had their medications given early. He stated he informed the DON to complete assessments on the resident's, document in the nurses notes and notify the physicians and representatives. During an interview on 04/24/2024 at 10:31 AM, the MD stated he was not notified of the medication errors with prescribed medications being administered to resident' s outside to the parameters as written on 04/12/2024 until the evening of 04/23/2024. He stated that his expectations were to be notified the day the of the medication error, for one resident and one medication, much less for the residents under his care on three halls. He stated there were not any negative outcomes for any residents, but he would have expected to have been notified at the time of the incident. During an interview on 04/24/2024 at 2:47 PM, ADON B, stated she contacted the DON on 04/12/2024 and notified her the MA F left around 5:30 PM and stated, everything is passed and she was going home. She stated the DON gave her guidance to figure out the residents that affected, complete assessments, and to report the information back to the DON. She stated she did not make notifications to the physicians, or resident's families. She stated she did not receive guidance from the DON to make any notifications. During an interview on 04/24/2024 at 3:24 PM, LVN C stated she did not make any notifications to the physicians or residents' families on 04/12/2024 about the medication errors. She stated she was under the impression based on a text message, that the DON would make the notifications and enter the assessments completed in the residents record as long as the information was sent to the DON. During an interview on 04/24/2024 at 3:50 PM, RN D, stated she was not aware of the medication errors on 04/12/2024 until 04/23/2024. She stated that she made notifications on 04/23/2024 to families, residents and physician. She stated when she notified the MD, he asked if there were any ill side effects and she explained none of the residents had any negative outcomes. She stated when she notified the NP, she asked if there were any ill side effects and she explained no, there were not any negative effects for any residents. During an interview on 04/24/2024 at 5:35 PM, the DON, stated she contacted the NP on 04/12/2024 for Resident #6 & #25 to let the NP know that Resident #6 could have received another resident medication and that there was a hiccup with Resident #27 and his 10 PM methadone (used for pain management). That the methadone was held that morning and he received the 10 PM dose around 6PM. She stated she told the nurses she would notify the NP. She stated she did not make any other notifications, and the staff should have notified the families and the physicians. She stated she did not follow up with the staff to ensure the notifications were made because LVN A is gone quite a bit, and ADON B is 676105 Page 3 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few always putting out fires, they would discuss the incident with the medication errors, but to circle back to it they were busy putting out other fires. The DON stated, she was out of town when the incident happened, then was on flex leave and when she returned to work there was a lot that week. During an interview on 04/24/2024 at 5:01 PM, the NP stated she was notified on 04/12/2024 by the DON and was told that the med aide decided to combine some medication times and give meds early and it involved some residents who take gabapentin. She stated the DON told her a couple of resident names on 04/12/2024. She stated she was provided a list of residents on 04/23/2024 and was not aware they had all been included in the incident on 04/12/2024. Stated she did not have concerns her the list of her residents the facility provided for the incident on 04/12/2024. She stated her main concerns were the medications. She stated her expectations were to have been notified at the time of the incident, the residents monitored, and she was very concerns about residents receiving medications incorrectly. Record review of the facility's in-service dated 02/22/2024 revealed staff were in-serviced on proper notification of MD, responsible party, family. Record review of the facility's in-service dated 04-23-2024 revealed staff were in service on medication error reporting. Record review of the facility policy Medication Error Reporting and Adverse Drug Reaction Prevention and Detection, dated 09/2010: Policy: The facility utilizes a system to assure that medication usage is evaluated on an ongoing basis. Medication errors and adverse drug reactions are assessed, documented, and reported as appropriate to the resident's attending physician and or prescribers, the Pharmaceutical Services Committee, the pharmacy, and Food and Drug Administration MedWatch program or USP/ISMP Medication Error Reporting Program (when applicable). Refer to state regulations if medication error and adverse reaction reporting programs are legislated. Guidelines and Definitions: 1. Medication error/variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the healthcare professional, resident or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing, order communication, product labeling, packaging, nomenclature, Compounding, dispensing, distribution, administration, education, monitoring and use. 6. In the event of a significant medication error or adverse drug reaction, immediate action is taken, as necessary, to protect the resident's safety and welfare. a. The prescriber is notified promptly of any significant error or adverse medication reaction. b. Any new prescriber's orders are implemented, and the resident is monitored closely for 24 to 72 676105 Page 4 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0580 hours or as directed. Level of Harm - Minimal harm or potential for actual harm c. The incident is described on a shift change report to alert staff of the need to monitor the resident. Residents Affected - Few d. The following information is documented in the residence medical record and or the incident report: factual description of the error or adverse reaction, name of prescriber and time notified, prescribers subsequent orders, residence condition for 24 to 72 hours or as directed. 676105 Page 5 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 39 of 46 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10,#11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, # 27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40 and #41) The facility failed to ensure MA F administered medications to (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10,#11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, # 27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40 and #41) accurately within the 2 hour window per physician orders. The facility failed to ensure Resident #6 did not receive another resident's medication during medication pass. The facility failed to reconcile narcotic sheets after MA F documented administering narcotic medications at a time she was not clocked in or working in the building. These failures could place residents at risk of receiving incorrect amounts of medication as prescribed by their physician or a resident to have an adverse reaction to medication not prescribed to the resident. Finding include: Record review of Resident #1 undated face sheet revealed an [AGE] year-old female. Resident #1 was originally admitted to the facility 07/22/2019 with the following diagnoses: Gastroesophageal reflux disease (condition in which the stomach contents move up into the esophagus), muscle weakness, constipation, insomnia (sleep disorder), and hyperlipidemia (high lipids in the blood). Record Review of Resident #1's quarterly MDS dated [DATE], Section C- Cognitive Patterns revealed no BIMS score which indicated resident was rarely/never understood. Record review of Resident #1's physician orders revealed active orders for 2.0 Cal Med Pass Supplement 120 Cubic centimeter by mouth 3 times per day scheduled for 7 AM, 1 PM, and 7 PM. (Fortified Nutritional Supplement) bethanechol chloride 10 mg tablet 1 tablet by mouth 3 times per day scheduled for 7 AM, 1 PM, and 7 PM. (Treats Bladder issues) lubiprostone 24 mcg capsule 1 capsule by mouth 2 times per day scheduled for 7 AM and 7PM. (Treats chronic constipation) melatonin 10 mg capsule 1 capsule by mouth at bedtime scheduled for 7 PM. (For sleep) omega 3-dha-epa-fish oil 1,000 mg, 1 capsule by mouth at bedtime scheduled for 7 PM. (To help lower triglyceride) 676105 Page 6 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0755 Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #1's medication administration record dated 4/12/2024, revealed the following undocumented medications for 7:00 PM: 2.0 Cal Med Pass Supplement 120 Cubic centimeter by mouth 3 times per day scheduled for 7 AM, 1 PM, and 7 PM. Residents Affected - Many bethanechol chloride 10 mg tablet 1 tablet by mouth 3 times per day scheduled for 7 AM, 1 PM, and 7 PM. lubiprostone 24 mcg capsule 1 capsule by mouth 2 times per day scheduled for 7 AM and 7PM. melatonin 10 mg capsule 1 capsule by mouth at bedtime scheduled for 7 PM. omega 3-dha-epa-fish oil 1,000 mg, 1 capsule by mouth at bedtime scheduled for 7 PM. Record Review of Resident #1's progress dated 4/12/2024 revealed Head to toe assessment performed at physician notification of medication error, revealed in nurse's notes. Record review of Resident #1's vital signs sheet dated 4/12/2024 at 9:16 PM revealed a Blood Pressure of 115/62, Pulse 79, Respirations 22, Temperature 97.3, and Oxygen Saturation 93%. Record review of Resident #2's undated face sheet revealed an [AGE] year-old female. Resident #2 was originally admitted on [DATE] with the following diagnoses is: Atrial fibrillation (heart arrythmia), Senile degeneration of brain, constipation, depressive disorder, iron deficiency, and disorder of the skin. Record review of Resident #2's Quarterly MDS dated [DATE], Section C- Cognitive Patterns revealed a BIMS score of 9 which indicated the resident had moderate cognitive impairment. Record review of Resident #2's physician orders revealed active orders for Eliquis 2.5 mg tablet 1 tablet by mouth 2 times per day scheduled for 7 AM and 7 PM. House Shake 1 CAN by mouth 3 times per day scheduled for 7 AM, 1 PM, and 7 PM. MiraLAX 17 gram/dose Oral Powder Gram by mouth 1 time per day mix with 4-8oz of water scheduled for 7PM. Multivitamin And Mineral tablet 1 tablet by mouth 1 time per day scheduled for 7 PM. mirtazapine 7.5 mg tablet 1 tablet by mouth at bedtime scheduled for 8PM. Acetaminophen- Cod #3 300mg-codeine 30 mg tablet, one tablet by mouth 2 times per day. Dose time adjusted do not change these times. Record review of Resident #2's medication administration record dated 4/12/2024 revealed the following undocumented medications for 7 PM: Eliquis 2.5 mg tablet 1 tablet by mouth 2 times per day scheduled for 7 AM and 7 PM. (To prevent 676105 Page 7 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0755 Blood Clots) Level of Harm - Minimal harm or potential for actual harm House Shake 1 CAN by mouth 3 times per day scheduled for 7 AM, 1 PM, and 7 PM. (extra calories and protein) Residents Affected - Many MiraLAX 17 gram/dose Oral Powder Gram by mouth 1 time per day mix with 4-8oz of water scheduled for 7PM. (treat occasional constipation) Multivitamin And Mineral tablet 1 tablet by mouth 1 time per day scheduled for 7 PM. (treat or prevent vitamin deficiency) Record review of Resident #2's medication administration record dated 4/12/2024 revealed the following undocumented medications for 8 PM. mirtazapine 7.5 mg tablet 1 tablet by mouth at bedtime scheduled for 8PM. Record review of the Controlled Drug Record for Resident #2- Individual Patients Narcotic Record dated 4/01/2024- 4/23/2024 revealed Acetaminophen- Cod #3 tablet documented on 4/12/2024 at 7 PM by MA F. Record Review of Resident #2's progress dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #2's vital signs sheet for 4/12/2024 at 9:16 PM revealed a BP of 136/66, pulse of 64, respirations 18, temperature of 96.5 F and oxygen saturation of 95. Record review of Resident #3's undated face sheet revealed a [AGE] year-old male. Resident #3 was originally admitted on [DATE] with the following diagnosis: hyperlipidemia (high lipids in the blood), atrial fibrillation (heart arrythmia), iron deficiency anemia (low iron), and hypertension (high blood pressure). Record review of Resident #3's annual MDS dated [DATE], Section C- Cognitive patterns revealed he had a BIMS score of 15 which indicated resident was cognitively intact. Record review of physician orders for Resident #3 revealed active orders for atorvastatin 20 mg tablet 1 tablet by mouth at bedtime, scheduled for 7pm. (lower bad cholesterol levels) ferrous sulfate 325 mg tablet, 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. (treat or prevent low blood levels of iron ) metoprolol succinate ER 100 mg tablet, extended release twice a day, scheduled for 7am and 7pm. (to treat chest pain (angina), heart failure, and high blood pressure) Eliquis 2.5 mg tablet 1 tablet by mouth 2 times per day scheduled, for 7am and 8pm. (prevent blood clots and stroke) Record review of Resident's 3 medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: 676105 Page 8 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0755 atorvastatin 20 mg tablet 1 tablet by mouth at bedtime, scheduled for 7pm. Level of Harm - Minimal harm or potential for actual harm ferrous sulfate 325 mg tablet, 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. metoprolol succinate ER 100 mg tablet, extended release twice a day, scheduled for 7am and 7pm. Residents Affected - Many Record review of Residents'3 medication administration record dated 4/12/2024 revealed the following undocumented medication for 8pm. Eliquis 2.5 mg tablet 1 tablet by mouth 2 times per day scheduled, for 7am and 8pm. Record review of Resident #3's nurses note dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #3's vital sign sheet dated 4/12/2024 at 9:19pm revealed a BP of 125/86, pulse of 60, respiratory rate of 20, temperature of 98.2 and oxygen saturation of 97. Record review of Resident #4's undated face sheet revealed a [AGE] year-old female. Resident #4 was originally admitted on [DATE] with the following diagnosis: constipation, Alzheimer's (disease of the brain), anxiety, schizoaffective disorder (chronic mental health condition), and pain unspecified. Record review of Resident #4's annual MDS dated [DATE], Section C- Cognitive patterns revealed he had a BIMS score of 0 which indicated resident was rarely/never understood. Record review of Resident #4's physician orders revealed active orders for Colace 100 mg tablet 1 tablet by mouth 2 times per, scheduled for 7 am and 7pm. (to relieve many symptoms of occasional constipation,) House Shake () 1 CAN by mouth 3 times per day House Shake, scheduled for7 AM, 1PM, and 7PM (added nutrition) lorazepam 0.5 mg tablet (LORAZEPAM) 1 tablet by mouth before meals and at bedtime, scheduled for 7 am, 11 am, 4 pm, and 7pm. (help to relieve anxiety) mirtazapine 30 mg tablet, 1 tablet by mouth at bedtime, schedule for 7pm. (to treat depression) quetiapine 100 mg tablet by mouth 3 times a day, scheduled for 7am, 1pm and 7pm. (to treat certain mental/mood disorders) senna 8.6 mg tablet (SENNOSIDES) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. (used to clean out the intestines) Tramadol 50mg tablet, by mouth 4 times ER day, scheduled for 7am, 11 am, 3pm, and 7pm. (to treat moderate to severe pain) Record review of Resident #4's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: 676105 Page 9 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0755 Colace 100 mg tablet 1 tablet by mouth 2 times per, scheduled for 7 am and 7pm. Level of Harm - Minimal harm or potential for actual harm House Shake () 1 CAN by mouth 3 times per day House Shake, scheduled for7 AM, 1PM, and 7PM Residents Affected - Many lorazepam 0.5 mg tablet (LORAZEPAM) 1 tablet by mouth before meals and at bedtime, scheduled for 7 am, 11 am, 4 pm, and 7pm. mirtazapine 30 mg tablet, 1 tablet by mouth at bedtime, schedule for 7pm. quetiapine 100 mg tablet by mouth 3 times a day, scheduled for 7am, 1pm and 7pm. senna 8.6 mg tablet (SENNOSIDES) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. Tramadol 50mg tablet, by mouth 4 times ER day, scheduled for 7am, 11 am, 3pm, and 7pm. Record review of Controlled Drug Record for Resident #4 Individual Patients Narcotic Record dated 4/09/2024- 4/23/2024 revealed lorazepam 0.5mg documented on 4/12/2024 at 1900 by MA F. Record review of Resident #4's nurses note dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #4's vital sign sheet dated 4/12/2024 at 9:20 pm revealed a BP of 97/51 pulse of 85, respiratory rate of 18, temperature of 96.7 and oxygen saturation of 95. Record review of Resident #5's undated face sheet revealed a [AGE] year-old female. Resident #5 was originally admitted on [DATE] with the following diagnosis: Major depressive disorder, constipation, chronic pain, dysphagia (difficulty or inability to swallow), seizures, and restless leg syndrome. Record review of Resident #5's annual MDS dated [DATE], Section C- Cognitive patterns revealed he had a BIMS score of 13 which indicated resident is cognitively intact. Record review of physician orders for Resident #5 revealed active orders for bupropion HCL 75 mg tablet (BUPROPION HCL) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. (to treat depression)) docusate sodium 100 mg tablet (DOCUSATE SODIUM) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. (treat occasional constipation) gabapentin 300 mg capsule (GABAPENTIN) 1 capsule by mouth 2 times per day, scheduled for 7 am and 7pm. ( to prevent and control seizures and used to relieve nerve pain) House Shake () 1 CAN by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. (to provide nutrition) primidone 50 mg tablet (PRIMIDONE) 0.5 tablet by mouth at bedtime, scheduled for 7pm. (to control seizures) 676105 Page 10 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0755 Level of Harm - Minimal harm or potential for actual harm ropinirole 1 mg tablet (ROPINIROLE HCL) 1 tablet by mouth at bedtime, scheduled for 8pm. (to control seizures) Record review of Resident #5's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: Residents Affected - Many bupropion HCL 75 mg tablet (BUPROPION HCL) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. docusate sodium 100 mg tablet (DOCUSATE SODIUM) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. gabapentin 300 mg capsule (GABAPENTIN) 1 capsule by mouth 2 times per day, scheduled for 7 am and 7pm. House Shake () 1 CAN by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. primidone 50 mg tablet (PRIMIDONE) 0.5 tablet by mouth at bedtime, scheduled for 7pm. Record review of Resident #5's medication administration record dated 4/12/2024 revealed the following undocumented medications for 8 PM. ropinirole 1 mg tablet (ROPINIROLE HCL) 1 tablet by mouth at bedtime, scheduled for 8pm. Record review of Resident #5's nurses note dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #5's vital sign sheet dated 4/12/2024 at 9:30 pm revealed a BP of 133/96, pulse of 108, respiratory rate of 16, temperature of 98.1 and oxygen saturation of 96. Record review of Resident #6's undated face sheet revealed a [AGE] year-old male. Resident #6 was originally admitted on [DATE] with the following diagnosis: hyperlipidemia (elevated lipids in the blood), cerebral infarction (disrupted blood flow to the brain), protein-calorie malnutrition, and neuropathic bladder (lack of bladder control). Record review of Resident #6's annual MDS dated [DATE], Section C- Cognitive patterns revealed he had a BIMS score of 15 which indicated resident is cognitively intact. Record review of physician orders for Resident #6 revealed active orders for atorvastatin 20 mg tablet (ATORVASTATIN CALCIUM) 1 tablet by mouth at bedtime, scheduled for 7pm. (lower bad cholesterol levels) clopidogrel 75 mg tablet (CLOPIDOGREL BISULFATE) 1 tablet by mouth 1 time per day, scheduled for 7pm.( a platelet inhibitor) mirtazapine 7.5 mg tablet (MIRTAZAPINE) 1 tablet by mouth at bedtime, scheduled for 7pm. (treat depression) 676105 Page 11 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many tamsulosin 0.4 mg capsule (TAMSULOSIN HCL) 0.4mg capsule by mouth 1 time per day scheduled for 7pm. ( treat the symptoms of an enlarged prostate) thiamine HCl (vitamin B1) 100 mg tablet (THIAMINE HCL) 1 tablet by mouth 1 time per day, scheduled for 7pm. (Thiamine is required by our bodies to properly use carbohydrates) Record review of Resident #6's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: atorvastatin 20 mg tablet (ATORVASTATIN CALCIUM) 1 tablet by mouth at bedtime, scheduled for 7pm. clopidogrel 75 mg tablet (CLOPIDOGREL BISULFATE) 1 tablet by mouth 1 time per day, scheduled for 7pm. mirtazapine 7.5 mg tablet (MIRTAZAPINE) 1 tablet by mouth at bedtime, scheduled for 7pm. tamsulosin 0.4 mg capsule (TAMSULOSIN HCL) 0.4mg capsule by mouth 1 time per day scheduled for 7pm. thiamine HCl (vitamin B1) 100 mg tablet (THIAMINE HCL) 1 tablet by mouth 1 time per day, scheduled for 7pm. Record review of Resident #6's nurses note dated 4/12/2024 revealed Late entry Head to toe assessment to NP to let her know about the Xarelto given and then Plavix held. and she said resumed Plavix tmrw. Record review of Resident #6's vital sign sheet dated 4/12/2024 at 9:35 pm revealed a BP of 135/72, pulse of 68, respiratory rate of 20, temperature of 97.6 and oxygen saturation of 95. Record review of Resident #7's undated face sheet revealed a [AGE] year-old male. Resident #7 was originally admitted to the facility on [DATE] with the following diagnosis: hypertension (high blood pressure). Record review of Resident #7s quarterly MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 9 which indicated resident had moderately impaired cognition. Record review of physician orders for Resident #7 revealed active orders for Eliquis 5 mg tablet (APIXABAN) 1 tablet by mouth 2 times per day scheduled for 7am and 7pm. ( reduces blood clotting) Record review of Resident #7's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: Eliquis 5 mg tablet (APIXABAN) 1 tablet by mouth 2 times per day scheduled for 7am and 7pm. Record review of Resident #7's nurses notes dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #7's vital signs sheet dated 4/12/2024 at 09:31 PM revealed a blood pressure of 124/60, pulse 45, temperature 97.8, respirations 24, and O2 saturation of 95. 676105 Page 12 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Record review of Resident #8's undated face sheet revealed a [AGE] year-old female. Resident #8 was originally admitted to the facility on [DATE] with the following diagnosis: anxiety, dementia, mood disturbance, peripheral neuropathy, insomnia, type 2 diabetes, allergies, and hyperlipidemia (elevated lipid levels in the blood). Record review of Resident #8's quarterly MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 14 which indicated resident was cognitively intact. Record review of physician orders for Resident #8 revealed active orders for alprazolam 0.5 mg tablet (ALPRAZOLAM) 1 tablet by mouth at bedtime scheduled for 7 pm. (treat anxiety and panic disorders_ donepezil 10 mg tablet (DONEPEZIL HCL) 1 tablet by mouth at bedtime scheduled for 7 pm. ( treat confusion (dementia) related to Alzheimer's disease) gabapentin 600 mg tablet (GABAPENTIN) 2 tablet by mouth at bedtime scheduled for 7 pm. (used to relieve nerve pain) melatonin 3 mg tablet (MELATONIN) 2 tablet by mouth at bedtime scheduled for 7 pm. (to help with sleep) metformin 500 mg tablet (METFORMIN HCL) 1 tablet by mouth 2 times per day scheduled for 7am and 7pm. (Used in patients with type 2 diabetes) Mucinex 600 mg tablet, extended release (GUAIFENESIN) 1 tablet extended release 12hr by mouth 2 times per day scheduled for 7am and 7pm. (temporary relief of coughs caused by the common cold, bronchitis, and other breathing illnesses) simvastatin 20 mg tablet (SIMVASTATIN) 1 tablet by mouth at bedtime scheduled for 7pm. (reducing the amount of cholesterol made by the liver.) Record review of Resident #8's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: alprazolam 0.5 mg tablet (ALPRAZOLAM) 1 tablet by mouth at bedtime scheduled for 7 pm. donepezil 10 mg tablet (DONEPEZIL HCL) 1 tablet by mouth at bedtime scheduled for 7 pm. gabapentin 600 mg tablet (GABAPENTIN) 2 tablet by mouth at bedtime scheduled for 7 pm. melatonin 3 mg tablet (MELATONIN) 2 tablet by mouth at bedtime scheduled for 7 pm. metformin 500 mg tablet (METFORMIN HCL) 1 tablet by mouth 2 times per day scheduled for 7am and 7pm. Mucinex 600 mg tablet, extended release (GUAIFENESIN) 1 tablet extended release 12hr by mouth 2 times per day scheduled for 7am and 7pm. simvastatin 20 mg tablet (SIMVASTATIN) 1 tablet by mouth at bedtime scheduled for 7pm. 676105 Page 13 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Record review of Controlled Drug Record- Individual Patients Narcotic Record dated 3/31/2024- 4/22/2024 revealed alprazolam 0.5mg documented on 4/12/2024 at 1900 by MA. Record review of Resident #8's nurses notes dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #8's vital signs sheet dated 4/12/2024 at 09:35pm revealed a blood pressure of 126/70, pulse of 67, respirations of 18, temperature of 97.4 and O2 saturation of 95%. Record review of Resident #9's undated face sheet revealed an [AGE] year-old female. Resident #9 was originally admitted to the facility on [DATE] with the following diagnosis: lack of coordination, and hypertension (high blood pressure). Record review of Resident #9's quarterly MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 0 which indicates resident was rarely/never understood. Record review of physician orders for Resident #9 revealed active orders for cranberry 450 mg tablet (cranberry fruit) 1 tablet by mouth at bedtime scheduled for 7pm. (support immune health) lisinopril 20 mg tablet (LISINOPRIL) 1 tablet by mouth 2 times per day scheduled for 7am and 7pm. (to treat high blood pressure) metoprolol succinate ER 50 mg tablet, extended release 24 hr. (METOPROLOL SUCCINATE) 1 tablet extended release 24 hr. by mouth 2 times per day, scheduled for 7 am and 7pm ( a beta-blocker used to treat chest pain) Record review of Resident #9's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: cranberry 450 mg tablet (cranberry fruit) 1 tablet by mouth at bedtime scheduled for 7pm. lisinopril 20 mg tablet (LISINOPRIL) 1 tablet by mouth 2 times per day scheduled for 7am and 7pm. metoprolol succinate ER 50 mg tablet, extended release 24 hr. (METOPROLOL SUCCINATE) 1 tablet extended release 24 hr. by mouth 2 times per day, scheduled for 7 am and 7pm Record review of Resident #9's nurses notes dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #9's vital signs sheet dated 4/12/2024 at 09:36 PM revealed a blood pressure of 94/48, pulse 60, temperature 96.9, respirations 16, and O2 saturation of 89. Record review of Resident #10's undated face sheet revealed an [AGE] year-old male. Resident #10 was originally admitted to the facility on [DATE] with the following diagnosis: hypertension (high blood pressure), and depression. Record review of Resident #10's quarterly MDS dated [DATE] revealed Section C- Cognitive pattern a 676105 Page 14 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0755 BIMS score of 07 which indicated resident had moderately impaired cognition. Level of Harm - Minimal harm or potential for actual harm Record review of physician orders for Resident #10 revealed active orders for clonidine 0.1 mg/24 hr. weekly transdermal patch (CLONIDINE) 0.1 Patch Weekly topically every Friday scheduled for 4/12/2024 at 7pm. (treat hypertension) Residents Affected - Many divalproex 250 mg tablet, delayed release (DIVALPROEX SODIUM) 1 tablet, delayed release (DR/EC) by mouth 2 times per day, scheduled for 7am and 7pm. (to treat certain types of seizures) Record review of Resident #10's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: clonidine 0.1 mg/24 hr. weekly transdermal patch (CLONIDINE) 0.1 Patch Weekly topically every Friday scheduled for 4/12/2024 at 7pm. divalproex 250 mg tablet, delayed release (DIVALPROEX SODIUM) 1 tablet, delayed release (DR/EC) by mouth 2 times per day, scheduled for 7am and 7pm. Record review of Resident #10's nurses notes dated 4/12/2024 revealed Late entry Head to toe assessment performed at 19:20, no abnormalities noted. no abnormalities noted, refused vitals to be taken. medication error, revealed in nurse's notes. Record review of Resident #10's vital sign sheet dated 4/12/2024 revealed resident refused to have his vital signs taken. Record review of Resident #11's undated face sheet revealed a [AGE] year-old male. Resident #11 was originally admitted to the facility on [DATE] with the following diagnosis: heart failure, constipation, and benign prostatic hyperplasia (enlarged prostate). Record review of Resident #11s quarterly MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 14 which indicated resident was cognitively intact. Record review of physician orders for Resident #10 revealed active orders for apixaban 5 mg tablet (APIXABAN) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. ( to prevent serious blood clots from forming due to a certain irregular heartbeat) MiraLAX 17 gram/dose Oral Powder (POLYETHYLENE GLYCOL 3350) 17 Gram by mouth Monday, Wednesday, and Friday, scheduled for 4/12/2024 at 7pm. (to treat constipation) tamsulosin 0.4 mg capsule (TAMSULOSIN HCL) 1 capsule by mouth at bedtime, scheduled for 7pm. (treat the symptoms of an enlarged prostate) Record review of Resident #11's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: apixaban 5 mg tablet (APIXABAN) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. MiraLAX 17 gram/dose Oral Powder (POLYETHYLENE GLYCOL 3350) 17 Gram by mouth Monday, Wednesday, and 676105 Page 15 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0755 Friday, scheduled for 4/12/2024 at 7pm. Level of Harm - Minimal harm or potential for actual harm tamsulosin 0.4 mg capsule (TAMSULOSIN HCL) 1 capsule by mouth at bedtime, scheduled for 7pm. Residents Affected - Many Record review of Resident #11's nurses notes dated 4/12/2024 revealed Late entry Head to toe PM. No documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #11's vital signs sheet dated 4/12/2024 at 09:39 PM revealed a blood pressure of 106/55, pulse 76, temperature 98.4, respirations 22, and O2 saturation of 95. Record review of Resident #12's undated face sheet revealed an [AGE] year-old male. Resident #12 was originally admitted to the facility on [DATE] with the following diagnosis: anxiety, pain, seizures, Parkinson's disease, and insomnia. Record review of Resident #12's admission MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 0 which indicated resident is rarely/never understood. Record review of physician orders for Resident #12 revealed active orders for acetaminophen 500 mg tablet (ACETAMINOPHEN) 1 tablet by mouth every 6 hours, scheduled for 12am, 6am, 12pm, and 6pm. (used to treat mild to moderate pain) buspirone 10 mg tablet (BUSPIRONE HCL) 1 tablet by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. (used to treat anxiety) buspirone 5 mg tablet (BUSPIRONE HCL) 1 tablet by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. (used to treat anxiety.) carbidopa ER 50 mg-levodopa 200 mg tablet, extended release (CARBIDOPA/LEVODOPA) 1 tablet extended release by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. (treat symptoms of Parkinson's disease) House Shake () 1 Liquid by mouth 3 times per day, scheduled for 7am, 1pm and 7pm. (added nutrition) levetiracetam 500 mg tablet (LEVETIRACETAM) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. (to treat seizures ) pramipexole 0.5 mg tablet (PRAMIPEXOLE DI-HCL) 1 tablet by mouth 4 times per day, scheduled for 7am, 11am, 3pm, and 7pm. (to treat Parkinson disease) Record review of Resident #12's medication administration record dated 4/12/2024 revealed the following undocumented medication for 6 pm: acetaminophen 500 mg tablet (ACETAMINOPHEN) 1 tablet by mouth every 6 hours, scheduled for 12am, 6am, 12pm, and 6pm. Record review of Resident #12's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: 676105 Page 16 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0755 Level of Harm - Minimal harm or potential for actual harm buspirone 10 mg tablet (BUSPIRONE HCL) 1 tablet by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. buspirone 5 mg tablet (BUSPIRONE HCL) 1 tablet by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. Residents Affected - Many carbidopa ER 50 mg-levodopa 200 mg tablet, extended release (CARBIDOPA/LEVODOPA) 1 tablet extended release by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. House Shake () 1 Liquid by mouth 3 times per day, scheduled for 7am, 1pm and 7pm. levetiracetam 500 mg tablet (LEVETIRACETAM) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. pramipexole 0.5 mg tablet (PRAMIPEXOLE DI-HCL) 1 tablet by mouth 4 times per day, scheduled for 7am, 11am, 3pm, and 7pm. Record review of Resident #12's medication administration record dated 4/12/2024 revealed the following undocumented medication for 8pm. melatonin 5 mg tablet (MELATONIN) 1 tablet by mouth at bedtime, scheduled at 8pm. Record review of Resident #12's nurses notes dated 4/12/2024 revealed Late entry Head to toe PM. No documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #12's vital signs sheet dated 4/12/2024 at 09:42 PM revealed a blood pressure of 118/72, pulse 90, temperature 98.5, respirations 16, and O2 saturation of 94. Record review of Resident #13's undated face sheet revealed a [AGE] year-old male. Resident #13 was originally admitted to the facility on [DATE] with the following diagnosis: elevated white blood cell count, muscle spasm, heart failure, cough, atrial fibrillation (heart beats irregularly), weight loss, seizures, and pain. Record review of Resident #13's quarterly MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 09 which indicated resident had moderately impaired cognition. Record review of physician orders for Resident #13 revealed active orders for Acidophilus Probiotic Blend 175 mg capsule (Lactobacillus acidophilus, salivarius/B.bifi [NAME]/S.thermophil) 1 capsule by mouth 1 time per day, scheduled for 7pm. (improve digestion and restore normal flora) aspirin 81 mg chewable tablet (ASPIRIN) 1 tablet by mouth 1 time per day, scheduled for 7pm. (relieve mild to moderate pain) atorvastatin 20 mg tablet (ATORVASTATIN CALCIUM) 1 tablet by mouth at bedtime, scheduled for 7pm. (to lower bad cholesterol levels) baclofen 5 mg tablet (baclofen) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. (treat muscle spasms) 676105 Page 17 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many dextromethorphan-guaifenesin 30 mg-600 mg tablet extended release12 hr (GUAIFENESIN/DEXTROMETHORPHAN HBR) 1 tablet extended release 12 hr by mouth 1 time per day, scheduled for 7pm. (used to relieve coughs caused by the common cold, bronchitis, and other breathing illnesses) Eliquis 5 mg tablet (APIXABAN) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. ( to prevent serious blood clots from forming due to a certain irregular heartbeat) fenofibrate 54 mg tablet (FENOFIBRATE) 1 tablet by mouth 1 time per day, scheduled for 7pm. (works by increasing the natural substance (enzyme) that breaks down fats in the blood) gabapentin 100 mg capsule (GABAPENTIN) 1 capsule by mouth 2 times per day, scheduled for 7am and 7pm. (to prevent and control seizures. It is also used to relieve nerve pain) phenytoin sodium extended 100 mg capsule (PHENYTOIN SODIUM EXTENDED) 676105 Page 18 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to maintian residnet medical records in accordance with accepted professional standards and practicies. The facility must maintain medical records on each resident that are accurately documented. The facility failed to ensure staff documented medications given to residents in the Medication Administration Record for 41 of 46 ((Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10,#11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, # 27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40 and #41) ) reviewed for acurrate documentation. This failure could place residents at risk of receiving incorrect amounts of medication as prescribed by their physician Finding include: Record review of Resident #1 undated face sheet revealed an [AGE] year-old female. Resident #1 was originally admitted to the facility 07/22/2019 with the following diagnoses: Gastroesophageal reflux disease (condition in which the stomach contents move up into the esophagus), muscle weakness, constipation, insomnia (sleep disorder), and hyperlipidemia (high lipids in the blood). Record Review of Resident #1's quarterly MDS dated [DATE], Section C- Cognitive Patterns revealed no BIMS score which indicated resident was rarely/never understood. Record review of Resident #1's physician orders revealed active orders for 2.0 Cal Med Pass Supplement 120 Cubic centimeter by mouth 3 times per day scheduled for 7 AM, 1 PM, and 7 PM. (Fortified Nutritional Supplement) bethanechol chloride 10 mg tablet 1 tablet by mouth 3 times per day scheduled for 7 AM, 1 PM, and 7 PM. (Treats Bladder issues) lubiprostone 24 mcg capsule 1 capsule by mouth 2 times per day scheduled for 7 AM and 7PM. (Treats chronic constipation) melatonin 10 mg capsule 1 capsule by mouth at bedtime scheduled for 7 PM. (For sleep) omega 3-dha-epa-fish oil 1,000 mg, 1 capsule by mouth at bedtime scheduled for 7 PM. (To help lower triglyceride) Record Review of Resident #1's medication administration record dated 4/12/2024, revealed the following undocumented medications for 7:00 PM: 2.0 Cal Med Pass Supplement 120 Cubic centimeter by mouth 3 times per day scheduled for 7 AM, 1 PM, and 7 PM. bethanechol chloride 10 mg tablet 1 tablet by mouth 3 times per day scheduled for 7 AM, 1 PM, and 7 PM. 676105 Page 19 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0842 lubiprostone 24 mcg capsule 1 capsule by mouth 2 times per day scheduled for 7 AM and 7PM. Level of Harm - Minimal harm or potential for actual harm melatonin 10 mg capsule 1 capsule by mouth at bedtime scheduled for 7 PM. omega 3-dha-epa-fish oil 1,000 mg, 1 capsule by mouth at bedtime scheduled for 7 PM. Residents Affected - Many Record Review of Resident #1's progress dated 4/12/2024 revealed Head to toe assessment performed at physician notification of medication error, revealed in nurse's notes. Record review of Resident #1's vital signs sheet dated 4/12/2024 at 9:16 PM revealed a Blood Pressure of 115/62, Pulse 79, Respirations 22, Temperature 97.3, and Oxygen Saturation 93%. Record review of Resident #2's undated face sheet revealed an [AGE] year-old female. Resident #2 was originally admitted on [DATE] with the following diagnoses is: Atrial fibrillation (heart arrythmia), Senile degeneration of brain, constipation, depressive disorder, iron deficiency, and disorder of the skin. Record review of Resident #2's Quarterly MDS dated [DATE], Section C- Cognitive Patterns revealed a BIMS score of 9 which indicated the resident had moderate cognitive impairment. Record review of Resident #2's physician orders revealed active orders for Eliquis 2.5 mg tablet 1 tablet by mouth 2 times per day scheduled for 7 AM and 7 PM. House Shake 1 CAN by mouth 3 times per day scheduled for 7 AM, 1 PM, and 7 PM. MiraLAX 17 gram/dose Oral Powder Gram by mouth 1 time per day mix with 4-8oz of water scheduled for 7PM. Multivitamin And Mineral tablet 1 tablet by mouth 1 time per day scheduled for 7 PM. mirtazapine 7.5 mg tablet 1 tablet by mouth at bedtime scheduled for 8PM. Acetaminophen- Cod #3 300mg-codeine 30 mg tablet, one tablet by mouth 2 times per day. Dose time adjusted do not change these times. Record review of Resident #2's medication administration record dated 4/12/2024 revealed the following undocumented medications for 7 PM: Eliquis 2.5 mg tablet 1 tablet by mouth 2 times per day scheduled for 7 AM and 7 PM. (To prevent Blood Clots) House Shake 1 CAN by mouth 3 times per day scheduled for 7 AM, 1 PM, and 7 PM. (extra calories and protein) MiraLAX 17 gram/dose Oral Powder Gram by mouth 1 time per day mix with 4-8oz of water scheduled for 7PM. (treat occasional constipation) Multivitamin And Mineral tablet 1 tablet by mouth 1 time per day scheduled for 7 PM. (treat or 676105 Page 20 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0842 prevent vitamin deficiency) Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's medication administration record dated 4/12/2024 revealed the following undocumented medications for 8 PM. Residents Affected - Many mirtazapine 7.5 mg tablet 1 tablet by mouth at bedtime scheduled for 8PM. Record review of the Controlled Drug Record for Resident #2- Individual Patients Narcotic Record dated 4/01/2024- 4/23/2024 revealed Acetaminophen- Cod #3 tablet documented on 4/12/2024 at 7 PM by MA F. Record Review of Resident #2's progress dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #2's vital signs sheet for 4/12/2024 at 9:16 PM revealed a BP of 136/66, pulse of 64, respirations 18, temperature of 96.5 F and oxygen saturation of 95. Record review of Resident #3's undated face sheet revealed a [AGE] year-old male. Resident #3 was originally admitted on [DATE] with the following diagnosis: hyperlipidemia (high lipids in the blood), atrial fibrillation (heart arrythmia), iron deficiency anemia (low iron), and hypertension (high blood pressure). Record review of Resident #3's annual MDS dated [DATE], Section C- Cognitive patterns revealed he had a BIMS score of 15 which indicated resident was cognitively intact. Record review of physician orders for Resident #3 revealed active orders for atorvastatin 20 mg tablet 1 tablet by mouth at bedtime, scheduled for 7pm. (lower bad cholesterol levels) ferrous sulfate 325 mg tablet, 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. (treat or prevent low blood levels of iron ) metoprolol succinate ER 100 mg tablet, extended release twice a day, scheduled for 7am and 7pm. (to treat chest pain (angina), heart failure, and high blood pressure) Eliquis 2.5 mg tablet 1 tablet by mouth 2 times per day scheduled, for 7am and 8pm. (prevent blood clots and stroke)Record review of Resident's 3 medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: atorvastatin 20 mg tablet 1 tablet by mouth at bedtime, scheduled for 7pm. ferrous sulfate 325 mg tablet, 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. metoprolol succinate ER 100 mg tablet, extended release twice a day, scheduled for 7am and 7pm. Record review of Residents'3 medication administration record dated 4/12/2024 revealed the following undocumented medication for 8pm. Eliquis 2.5 mg tablet 1 tablet by mouth 2 times per day scheduled, for 7am and 8pm. 676105 Page 21 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Record review of Resident #3's nurses note dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #3's vital sign sheet dated 4/12/2024 at 9:19pm revealed a BP of 125/86, pulse of 60, respiratory rate of 20, temperature of 98.2 and oxygen saturation of 97. Record review of Resident #4's undated face sheet revealed a [AGE] year-old female. Resident #4 was originally admitted on [DATE] with the following diagnosis: constipation, Alzheimer's (disease of the brain), anxiety, schizoaffective disorder (chronic mental health condition), and pain unspecified. Record review of Resident #4's annual MDS dated [DATE], Section C- Cognitive patterns revealed he had a BIMS score of 0 which indicated resident was rarely/never understood. Record review of Resident #4's physician orders revealed active orders for Colace 100 mg tablet 1 tablet by mouth 2 times per, scheduled for 7 am and 7pm. (to relieve many symptoms of occasional constipation,) House Shake () 1 CAN by mouth 3 times per day House Shake, scheduled for7 AM, 1PM, and 7PM (added nutrition) lorazepam 0.5 mg tablet (LORAZEPAM) 1 tablet by mouth before meals and at bedtime, scheduled for 7 am, 11 am, 4 pm, and 7pm. (help to relieve anxiety) mirtazapine 30 mg tablet, 1 tablet by mouth at bedtime, schedule for 7pm. (to treat depression) quetiapine 100 mg tablet by mouth 3 times a day, scheduled for 7am, 1pm and 7pm. (to treat certain mental/mood disorders) senna 8.6 mg tablet (SENNOSIDES) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. (used to clean out the intestines) Tramadol 50mg tablet, by mouth 4 times ER day, scheduled for 7am, 11 am, 3pm, and 7pm. (to treat moderate to severe pain) Record review of Resident #4's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: Colace 100 mg tablet 1 tablet by mouth 2 times per, scheduled for 7 am and 7pm. House Shake () 1 CAN by mouth 3 times per day House Shake, scheduled for7 AM, 1PM, and 7PM lorazepam 0.5 mg tablet (LORAZEPAM) 1 tablet by mouth before meals and at bedtime, scheduled for 7 am, 11 am, 4 pm, and 7pm. mirtazapine 30 mg tablet, 1 tablet by mouth at bedtime, schedule for 7pm. quetiapine 100 mg tablet by mouth 3 times a day, scheduled for 7am, 1pm and 7pm. 676105 Page 22 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0842 senna 8.6 mg tablet (SENNOSIDES) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. Level of Harm - Minimal harm or potential for actual harm Tramadol 50mg tablet, by mouth 4 times ER day, scheduled for 7am, 11 am, 3pm, and 7pm. Residents Affected - Many Record review of Controlled Drug Record for Resident #4 Individual Patients Narcotic Record dated 4/09/2024- 4/23/2024 revealed lorazepam 0.5mg documented on 4/12/2024 at 1900 by MA F. Record review of Resident #4's nurses note dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #4's vital sign sheet dated 4/12/2024 at 9:20 pm revealed a BP of 97/51 pulse of 85, respiratory rate of 18, temperature of 96.7 and oxygen saturation of 95. Record review of Resident #5's undated face sheet revealed a [AGE] year-old female. Resident #5 was originally admitted on [DATE] with the following diagnosis: Major depressive disorder, constipation, chronic pain, dysphagia (difficulty or inability to swallow), seizures, and restless leg syndrome. Record review of Resident #5's annual MDS dated [DATE], Section C- Cognitive patterns revealed he had a BIMS score of 13 which indicated resident is cognitively intact. Record review of physician orders for Resident #5 revealed active orders for bupropion HCL 75 mg tablet (BUPROPION HCL) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. (to treat depression)) docusate sodium 100 mg tablet (DOCUSATE SODIUM) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. (treat occasional constipation) gabapentin 300 mg capsule (GABAPENTIN) 1 capsule by mouth 2 times per day, scheduled for 7 am and 7pm. ( to prevent and control seizures and used to relieve nerve pain) House Shake () 1 CAN by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. (to provide nutrition) primidone 50 mg tablet (PRIMIDONE) 0.5 tablet by mouth at bedtime, scheduled for 7pm. (to control seizures) ropinirole 1 mg tablet (ROPINIROLE HCL) 1 tablet by mouth at bedtime, scheduled for 8pm. (to control seizures)Record review of Resident #5's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: bupropion HCL 75 mg tablet (BUPROPION HCL) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. docusate sodium 100 mg tablet (DOCUSATE SODIUM) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. gabapentin 300 mg capsule (GABAPENTIN) 1 capsule by mouth 2 times per day, scheduled for 7 am and 676105 Page 23 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0842 7pm. Level of Harm - Minimal harm or potential for actual harm House Shake () 1 CAN by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. primidone 50 mg tablet (PRIMIDONE) 0.5 tablet by mouth at bedtime, scheduled for 7pm. Residents Affected - Many Record review of Resident #5's medication administration record dated 4/12/2024 revealed the following undocumented medications for 8 PM. ropinirole 1 mg tablet (ROPINIROLE HCL) 1 tablet by mouth at bedtime, scheduled for 8pm. Record review of Resident #5's nurses note dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #5's vital sign sheet dated 4/12/2024 at 9:30 pm revealed a BP of 133/96, pulse of 108, respiratory rate of 16, temperature of 98.1 and oxygen saturation of 96. Record review of Resident #6's undated face sheet revealed a [AGE] year-old male. Resident #6 was originally admitted on [DATE] with the following diagnosis: hyperlipidemia (elevated lipids in the blood), cerebral infarction (disrupted blood flow to the brain), protein-calorie malnutrition, and neuropathic bladder (lack of bladder control). Record review of Resident #6's annual MDS dated [DATE], Section C- Cognitive patterns revealed he had a BIMS score of 15 which indicated resident is cognitively intact. Record review of physician orders for Resident #6 revealed active orders for atorvastatin 20 mg tablet (ATORVASTATIN CALCIUM) 1 tablet by mouth at bedtime, scheduled for 7pm. (lower bad cholesterol levels) clopidogrel 75 mg tablet (CLOPIDOGREL BISULFATE) 1 tablet by mouth 1 time per day, scheduled for 7pm.( a platelet inhibitor) mirtazapine 7.5 mg tablet (MIRTAZAPINE) 1 tablet by mouth at bedtime, scheduled for 7pm. (treat depression) tamsulosin 0.4 mg capsule (TAMSULOSIN HCL) 0.4mg capsule by mouth 1 time per day scheduled for 7pm. ( treat the symptoms of an enlarged prostate) thiamine HCl (vitamin B1) 100 mg tablet (THIAMINE HCL) 1 tablet by mouth 1 time per day, scheduled for 7pm. (Thiamine is required by our bodies to properly use carbohydrates) Record review of Resident #6's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: atorvastatin 20 mg tablet (ATORVASTATIN CALCIUM) 1 tablet by mouth at bedtime, scheduled for 7pm. clopidogrel 75 mg tablet (CLOPIDOGREL BISULFATE) 1 tablet by mouth 1 time per day, scheduled for 7pm. 676105 Page 24 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0842 mirtazapine 7.5 mg tablet (MIRTAZAPINE) 1 tablet by mouth at bedtime, scheduled for 7pm. Level of Harm - Minimal harm or potential for actual harm tamsulosin 0.4 mg capsule (TAMSULOSIN HCL) 0.4mg capsule by mouth 1 time per day scheduled for 7pm. Residents Affected - Many thiamine HCl (vitamin B1) 100 mg tablet (THIAMINE HCL) 1 tablet by mouth 1 time per day, scheduled for 7pm. Record review of Resident #6's nurses note dated 4/12/2024 revealed Late entry Head to toe assessment to NP to let her know about the Xarelto given and then Plavix held. and she said resumed Plavix tmrw. Record review of Resident #6's vital sign sheet dated 4/12/2024 at 9:35 pm revealed a BP of 135/72, pulse of 68, respiratory rate of 20, temperature of 97.6 and oxygen saturation of 95. Record review of Resident #7's undated face sheet revealed a [AGE] year-old male. Resident #7 was originally admitted to the facility on [DATE] with the following diagnosis: hypertension (high blood pressure). Record review of Resident #7s quarterly MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 9 which indicated resident had moderately impaired cognition. Record review of physician orders for Resident #7 revealed active orders for Eliquis 5 mg tablet (APIXABAN) 1 tablet by mouth 2 times per day scheduled for 7am and 7pm. ( reduces blood clotting) Record review of Resident #7's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: Eliquis 5 mg tablet (APIXABAN) 1 tablet by mouth 2 times per day scheduled for 7am and 7pm. Record review of Resident #7's nurses notes dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #7's vital signs sheet dated 4/12/2024 at 09:31 PM revealed a blood pressure of 124/60, pulse 45, temperature 97.8, respirations 24, and O2 saturation of 95. Record review of Resident #8's undated face sheet revealed a [AGE] year-old female. Resident #8 was originally admitted to the facility on [DATE] with the following diagnosis: anxiety, dementia, mood disturbance, peripheral neuropathy, insomnia, type 2 diabetes, allergies, and hyperlipidemia (elevated lipid levels in the blood). Record review of Resident #8's quarterly MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 14 which indicated resident was cognitively intact. Record review of physician orders for Resident #8 revealed active orders for alprazolam 0.5 mg tablet (ALPRAZOLAM) 1 tablet by mouth at bedtime scheduled for 7 pm. (treat anxiety and panic disorders_ donepezil 10 mg tablet (DONEPEZIL HCL) 1 tablet by mouth at bedtime scheduled for 7 pm. ( treat 676105 Page 25 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0842 confusion (dementia) related to Alzheimer's disease) Level of Harm - Minimal harm or potential for actual harm gabapentin 600 mg tablet (GABAPENTIN) 2 tablet by mouth at bedtime scheduled for 7 pm. (used to relieve nerve pain) Residents Affected - Many melatonin 3 mg tablet (MELATONIN) 2 tablet by mouth at bedtime scheduled for 7 pm. (to help with sleep) metformin 500 mg tablet (METFORMIN HCL) 1 tablet by mouth 2 times per day scheduled for 7am and 7pm. (Used in patients with type 2 diabetes) Mucinex 600 mg tablet, extended release (GUAIFENESIN) 1 tablet extended release 12hr by mouth 2 times per day scheduled for 7am and 7pm. (temporary relief of coughs caused by the common cold, bronchitis, and other breathing illnesses) simvastatin 20 mg tablet (SIMVASTATIN) 1 tablet by mouth at bedtime scheduled for 7pm. (reducing the amount of cholesterol made by the liver.) Record review of Resident #8's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: alprazolam 0.5 mg tablet (ALPRAZOLAM) 1 tablet by mouth at bedtime scheduled for 7 pm. donepezil 10 mg tablet (DONEPEZIL HCL) 1 tablet by mouth at bedtime scheduled for 7 pm. gabapentin 600 mg tablet (GABAPENTIN) 2 tablet by mouth at bedtime scheduled for 7 pm. melatonin 3 mg tablet (MELATONIN) 2 tablet by mouth at bedtime scheduled for 7 pm. metformin 500 mg tablet (METFORMIN HCL) 1 tablet by mouth 2 times per day scheduled for 7am and 7pm. Mucinex 600 mg tablet, extended release (GUAIFENESIN) 1 tablet extended release 12hr by mouth 2 times per day scheduled for 7am and 7pm. simvastatin 20 mg tablet (SIMVASTATIN) 1 tablet by mouth at bedtime scheduled for 7pm. Record review of Controlled Drug Record- Individual Patients Narcotic Record dated 3/31/2024- 4/22/2024 revealed alprazolam 0.5mg documented on 4/12/2024 at 1900 by MA. Record review of Resident #8's nurses notes dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #8's vital signs sheet dated 4/12/2024 at 09:35pm revealed a blood pressure of 126/70, pulse of 67, respirations of 18, temperature of 97.4 and O2 saturation of 95%. Record review of Resident #9's undated face sheet revealed an [AGE] year-old female. Resident #9 was originally admitted to the facility on [DATE] with the following diagnosis: lack of coordination, 676105 Page 26 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0842 and hypertension (high blood pressure). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #9's quarterly MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 0 which indicates resident was rarely/never understood. Residents Affected - Many Record review of physician orders for Resident #9 revealed active orders for cranberry 450 mg tablet (cranberry fruit) 1 tablet by mouth at bedtime scheduled for 7pm. (support immune health) lisinopril 20 mg tablet (LISINOPRIL) 1 tablet by mouth 2 times per day scheduled for 7am and 7pm. (to treat high blood pressure) metoprolol succinate ER 50 mg tablet, extended release 24 hr. (METOPROLOL SUCCINATE) 1 tablet extended release 24 hr. by mouth 2 times per day, scheduled for 7 am and 7pm ( a beta-blocker used to treat chest pain) Record review of Resident #9's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: cranberry 450 mg tablet (cranberry fruit) 1 tablet by mouth at bedtime scheduled for 7pm. lisinopril 20 mg tablet (LISINOPRIL) 1 tablet by mouth 2 times per day scheduled for 7am and 7pm. metoprolol succinate ER 50 mg tablet, extended release 24 hr. (METOPROLOL SUCCINATE) 1 tablet extended release 24 hr. by mouth 2 times per day, scheduled for 7 am and 7pm Record review of Resident #9's nurses notes dated 4/12/2024 revealed Late entry Head to toe assessment documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #9's vital signs sheet dated 4/12/2024 at 09:36 PM revealed a blood pressure of 94/48, pulse 60, temperature 96.9, respirations 16, and O2 saturation of 89. Record review of Resident #10's undated face sheet revealed an [AGE] year-old male. Resident #10 was originally admitted to the facility on [DATE] with the following diagnosis: hypertension (high blood pressure), and depression. Record review of Resident #10's quarterly MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 07 which indicated resident had moderately impaired cognition. Record review of physician orders for Resident #10 revealed active orders for clonidine 0.1 mg/24 hr. weekly transdermal patch (CLONIDINE) 0.1 Patch Weekly topically every Friday scheduled for 4/12/2024 at 7pm. (treat hypertension) divalproex 250 mg tablet, delayed release (DIVALPROEX SODIUM) 1 tablet, delayed release (DR/EC) by mouth 2 times per day, scheduled for 7am and 7pm. (to treat certain types of seizures) Record review of Resident #10's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: 676105 Page 27 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0842 Level of Harm - Minimal harm or potential for actual harm clonidine 0.1 mg/24 hr. weekly transdermal patch (CLONIDINE) 0.1 Patch Weekly topically every Friday scheduled for 4/12/2024 at 7pm. divalproex 250 mg tablet, delayed release (DIVALPROEX SODIUM) 1 tablet, delayed release (DR/EC) by mouth 2 times per day, scheduled for 7am and 7pm. Residents Affected - Many Record review of Resident #10's nurses notes dated 4/12/2024 revealed Late entry Head to toe assessment performed at 19:20, no abnormalities noted. no abnormalities noted, refused vitals to be taken. medication error, revealed in nurse's notes. Record review of Resident #10's vital sign sheet dated 4/12/2024 revealed resident refused to have his vital signs taken. Record review of Resident #11's undated face sheet revealed a [AGE] year-old male. Resident #11 was originally admitted to the facility on [DATE] with the following diagnosis: heart failure, constipation, and benign prostatic hyperplasia (enlarged prostate). Record review of Resident #11s quarterly MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 14 which indicated resident was cognitively intact. Record review of physician orders for Resident #10 revealed active orders for apixaban 5 mg tablet (APIXABAN) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. ( to prevent serious blood clots from forming due to a certain irregular heartbeat) MiraLAX 17 gram/dose Oral Powder (POLYETHYLENE GLYCOL 3350) 17 Gram by mouth Monday, Wednesday, and Friday, scheduled for 4/12/2024 at 7pm. (to treat constipation) tamsulosin 0.4 mg capsule (TAMSULOSIN HCL) 1 capsule by mouth at bedtime, scheduled for 7pm. (treat the symptoms of an enlarged prostate) Record review of Resident #11's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: apixaban 5 mg tablet (APIXABAN) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. MiraLAX 17 gram/dose Oral Powder (POLYETHYLENE GLYCOL 3350) 17 Gram by mouth Monday, Wednesday, and Friday, scheduled for 4/12/2024 at 7pm. tamsulosin 0.4 mg capsule (TAMSULOSIN HCL) 1 capsule by mouth at bedtime, scheduled for 7pm. Record review of Resident #11's nurses notes dated 4/12/2024 revealed Late entry Head to toe PM. No documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #11's vital signs sheet dated 4/12/2024 at 09:39 PM revealed a blood pressure of 106/55, pulse 76, temperature 98.4, respirations 22, and O2 saturation of 95. Record review of Resident #12's undated face sheet revealed an [AGE] year-old male. Resident #12 676105 Page 28 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0842 Level of Harm - Minimal harm or potential for actual harm was originally admitted to the facility on [DATE] with the following diagnosis: anxiety, pain, seizures, Parkinson's disease, and insomnia. Record review of Resident #12's admission MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 0 which indicated resident is rarely/never understood. Residents Affected - Many Record review of physician orders for Resident #12 revealed active orders for acetaminophen 500 mg tablet (ACETAMINOPHEN) 1 tablet by mouth every 6 hours, scheduled for 12am, 6am, 12pm, and 6pm. (used to treat mild to moderate pain) buspirone 10 mg tablet (BUSPIRONE HCL) 1 tablet by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. (used to treat anxiety) buspirone 5 mg tablet (BUSPIRONE HCL) 1 tablet by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. (used to treat anxiety.) carbidopa ER 50 mg-levodopa 200 mg tablet, extended release (CARBIDOPA/LEVODOPA) 1 tablet extended release by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. (treat symptoms of Parkinson's disease) House Shake () 1 Liquid by mouth 3 times per day, scheduled for 7am, 1pm and 7pm. (added nutrition) levetiracetam 500 mg tablet (LEVETIRACETAM) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. (to treat seizures ) pramipexole 0.5 mg tablet (PRAMIPEXOLE DI-HCL) 1 tablet by mouth 4 times per day, scheduled for 7am, 11am, 3pm, and 7pm. (to treat Parkinson disease) Record review of Resident #12's medication administration record dated 4/12/2024 revealed the following undocumented medication for 6 pm: acetaminophen 500 mg tablet (ACETAMINOPHEN) 1 tablet by mouth every 6 hours, scheduled for 12am, 6am, 12pm, and 6pm. Record review of Resident #12's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: buspirone 10 mg tablet (BUSPIRONE HCL) 1 tablet by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. buspirone 5 mg tablet (BUSPIRONE HCL) 1 tablet by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. carbidopa ER 50 mg-levodopa 200 mg tablet, extended release (CARBIDOPA/LEVODOPA) 1 tablet extended release by mouth 3 times per day, scheduled for 7am, 1pm, and 7pm. House Shake () 1 Liquid by mouth 3 times per day, scheduled for 7am, 1pm and 7pm. levetiracetam 500 mg tablet (LEVETIRACETAM) 1 tablet by mouth 2 times per day, scheduled for 7am 676105 Page 29 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0842 and 7pm. Level of Harm - Minimal harm or potential for actual harm pramipexole 0.5 mg tablet (PRAMIPEXOLE DI-HCL) 1 tablet by mouth 4 times per day, scheduled for 7am, 11am, 3pm, and 7pm. Residents Affected - Many Record review of Resident #12's medication administration record dated 4/12/2024 revealed the following undocumented medication for 8pm. melatonin 5 mg tablet (MELATONIN) 1 tablet by mouth at bedtime, scheduled at 8pm. Record review of Resident #12's nurses notes dated 4/12/2024 revealed Late entry Head to toe PM. No documentation for physician notification of medication error, revealed in nurse's notes. Record review of Resident #12's vital signs sheet dated 4/12/2024 at 09:42 PM revealed a blood pressure of 118/72, pulse 90, temperature 98.5, respirations 16, and O2 saturation of 94. Record review of Resident #13's undated face sheet revealed a [AGE] year-old male. Resident #13 was originally admitted to the facility on [DATE] with the following diagnosis: elevated white blood cell count, muscle spasm, heart failure, cough, atrial fibrillation (heart beats irregularly), weight loss, seizures, and pain. Record review of Resident #13's quarterly MDS dated [DATE] revealed Section C- Cognitive pattern a BIMS score of 09 which indicated resident had moderately impaired cognition. Record review of physician orders for Resident #13 revealed active orders for Acidophilus Probiotic Blend 175 mg capsule (Lactobacillus acidophilus, salivarius/B.bifi [NAME]/S.thermophil) 1 capsule by mouth 1 time per day, scheduled for 7pm. (improve digestion and restore normal flora) aspirin 81 mg chewable tablet (ASPIRIN) 1 tablet by mouth 1 time per day, scheduled for 7pm. (relieve mild to moderate pain) atorvastatin 20 mg tablet (ATORVASTATIN CALCIUM) 1 tablet by mouth at bedtime, scheduled for 7pm. (to lower bad cholesterol levels) baclofen 5 mg tablet (baclofen) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. (treat muscle spasms) dextromethorphan-guaifenesin 30 mg-600 mg tablet extended release12 hr (GUAIFENESIN/DEXTROMETHORPHAN HBR) 1 tablet extended release 12 hr by mouth 1 time per day, scheduled for 7pm. (used to relieve coughs caused by the common cold, bronchitis, and other breathing illnesses) Eliquis 5 mg tablet (APIXABAN) 1 tablet by mouth 2 times per day, scheduled for 7am and 7pm. ( to prevent serious blood clots from forming due to a certain irregular heartbeat) fenofibrate 54 mg tablet (FENOFIBRATE) 1 tablet by mouth 1 time per day, scheduled for 7pm. (works by increasing the natural substance (enzyme) that breaks down fats in the blood) gabapentin 100 mg capsule (GABAPENTIN) 1 capsule by mouth 2 times per day, scheduled for 7am and 676105 Page 30 of 31 676105 04/24/2024 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0842 7pm. (to prevent and control seizures. It is also used to relieve nerve pain) Level of Harm - Minimal harm or potential for actual harm phenytoin sodium extended 100 mg capsule (PHENYTOIN SODIUM EXTENDED) 3 capsule by mouth at bedtime, scheduled for 7pm. (used to prevent and control seizures) Residents Affected - Many House Shake () 1 CAN by mouth 3 times per day House Shake, scheduled for 7am, 1pm, and 7pm. (to provide nutrition) Record review of Resident #13's medication administration record dated 4/12/2024 revealed the following undocumented medication for 7pm: Acidophilus Probiotic Blend 175 mg capsule (Lactobacillus acidophilus, salivarius/B.bifi [NAME]/S.thermophil) 1 capsule by mouth 1 time per day, scheduled for 7pm. aspirin 81 mg chewable tablet (ASP 676105 Page 31 of 31