Health inspection·February 7, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm male, admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction(stroke), Hemiplegia and Hemiparesis affecting left side(partial paralysis following stroke), Chronic Obstructive Pulmonary Disease(COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), Psoriatic arthritis(type of arthritis linked with psoriasis, a chronic skin and nail disease), Rheumatoid Arthritis(autoimmune inflammation of the joints), Pain in left leg. Residents Affected - Some Record Review of Resident #3's Controlled Substance Disposition Record and order for Hydroco/Apapa(Norco) Tab 7.5-325, Take 1 tablet by mouth every 6 hours as needed for pain revealed that RN signed out 1 tag on 1/25/24 at 8:00 a.m. Record Review of Resident #3's MAR for 1/25/24 revealed that Resident #1 was administered Norco 7/5/325 mg oat 01:40 a.m. and revealed no documented administration at 8:00 a.m.by RN. Record review of the ADM's timeline of events and screenshots of camera footage, signed and dated by the ADM on 2/7/24 revealed the following in part: 2/7/24: ADM at (Facility name) reviewed videos on [NAME] for Resident #2 room from the phone of Resident #2's FM, Upon reviewing the videos this is what I concluded: On 1/11/24 RN signed out a Norco 325 at 12 p.m. for Resident #2. After reviewing the video RN did not administer any medication to Resident #2, RN entered the room around 1:30 pm. only to look at Resident #2's catheter. On 1/23/24 LVN B signed out a Norco 325 at 0346, 1840 and 2346 for Resident #2. After reviewing the video LVN B did not administer medication at 0346 or 2346. On 1/24/24 LVN B signed out Norco 325 at 1830 and 2350 for Resident #2, LVN B did not administer the medication at 2350. On 1/31/24 LVN B signed out Norco 325 at 1905 and 2345 for Resident #2, LVN B administered the medication at approximately 1930 and did not administer medication at 2345. During an interview on 2/6/24 at 8:15 a.m. the ADM stated that the facility self-reported a medication diversion after it was discovered that Resident #2's Norco's were not being given correctly or documented in the MAR/EMAR. The ADM stated that during the facility investigation, the facility was drug testing the nurses and medication aides who had access to the carts that had Resident #2's medications in them. The ADM stated that the RN came to her and stated that he took one of Resident #3's Norco pain pills because he(RN) was having knee and back pain. The ADM stated that the RN documented he removed the pill from narcotic count sheet but did not put in in the MAR that he administered it to. The ADM stated that the RN was suspended, and she attempted to call him, but he did not return her call. The ADM stated that it was determined during the investigation that LVN B had been documenting that she removed 2 tabs from Resident #2's narcotic count sheet but had not put it in the MAR that it was administered. The ADM stated that Resident #2's orders are for 1 tab of 5/325 mg and LVN B was signing out 2 tabs of 5/325 mg. The ADM stated that Resident #2 cannot state whether she received the medication or not and it is also not in the MAR, so the facility was unable to determine if Resident #2 received the Norco. The ADM stated that LVN B tested negative, and Resident #2 tested positive for the narcotic. During an interview on 2/6/24 at 9:06 a.m., Corporate Liaison stated that the facility identified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 2 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some an issue with the count sheet for Resident #2 that showed the nurses were signing out 2 tabs of Norco 5/325mg instead of 1 tab. The Corporate Liaison stated that is what started the investigation and self-report and during the investigation they were drug testing all the nurses who had access to the medication carts. The Corporate Liaison stated that the RN stated he would test positive because he took one of Resident #3's Norco's on 1/25/24 because he had leg or back pain. The Corporate Liaison stated that LVN B tested negative for any controlled substances. The Corporate Liaison stated they determined there was medication diversion and misappropriation of property based on the RN confessing that he took one of Resident #3's pain meds. The Corporate Liaison stated that Resident #2's Norco's were signed out of the controlled substance logbook but never documented in the MAR by the nurses. The Corporate Liaison stated that Resident #2 tested positive for the Norco but that the test does not state how much was in her system or how long the medication had been in her system. The RN consultant stated she would provide the facility Abuse, Neglect and Misappropriation policy. During an interview on 2/6/24 at approximately 5:00 p.m. LVN B stated that she worked the 6 p.m. to 6 a.m. shift. LVN B stated that she had been administering 2 tabs of 5/325mg Norco to Resident #2 because that is what the old order from before August 2023 stated. LVN B stated that she did not log in the MAR that she administered Resident #2's Norco but stated she did give them to Resident #2. LVN B stated that she gave Resident #2 the medication and she did not take any medications from any resident. LVN B stated that she had been trained how to administer medications and would never steal from a resident. During an interview on 2/7/24 at 11:32 a.m. Resident #2 stated that she normally does not have pain and that sometimes she will ask for her night pain meds but not always. Resident #2 stated that she did not complain to the nurses at night that she was in pain and that sometimes she would get 1-2 meds at a time at night from a nurse. During an interview on 2/7/24 at 12:15 p.m. the ADM stated that she is reviewing footage from the camera that is in Resident #2's room that the family provided her. The ADM stated that she had already reviewed 4 occurrences where LVN B signed out the Norco for Resident #2 and did not give Resident #2 the medication, for a total of 7 Norco tabs. The ADM stated that she is the abuse coordinator for the facility. During an interview and observation on 2/7/24 at 1:30 p.m. with Resident #3 in the hallway he stated that he never had a problem getting his pain medications in the past and that he was aware that the RN took one of his pain medications. Resident #3 stated he did not want to press charges against the RN because he liked the RN and he is a pretty cool guy who made a mistake. Resident #3 stated he was not concerned about the missing Hydro pain pill. An attempted phone interview with RN was made on 2/7/24 at 1:44 p.m., phone was disconnected. Confirmation of phone number from facility ADM and facility records was made. A certified letter was mailed to RN on 2/12/24 with request for RN to contact HHSC Investigator via telephone. Record Review of the undated facility obtained written statement by RN revealed the following, On the morning of 1/25/24, I did take 1 of (Resident #3's) Norco 7.5mg/325 mg. I did so do to back and knee pain. I take full responsibility for my action which was a terrible error judgement. Signed by RN. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 3 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Level of Harm - Minimal harm or potential for actual harm Record Review of the disciplinary action form dated 1/25/24 for LVN B revealed: Nature of Offence: Gave Resident #2 twice the ordered amount of Hydrocodone (ordered 5-325mg) gave 2 (10-550mg) for a total of 25 doses. Signed out 50 doses of Hydrocodone but did not document in EMAR. Statement from LVN B: No one told me not to call hospice to reorder her medications or did I know about any issues. Will follow orders closely. Residents Affected - Some Record review of the Provider Investigation Report dated 1/25/24 revealed: The facility self-reported a drug diversion incident that occurred on 1/25/24. The PIR documented that RN stated that he consumed 1 of Resident #3's 7.5 Norco's and that the facility reported RN to the Texas Board of Nursing and suspended the RN. The Police were contacted and interviewed the RN, but no charges could be made as the RN did not have possession of the Norco because he ingested it. Record Review of In-service on 1/26/24 for LVN B revealed summary of training session: No meds/treatments may be administered without a physician order. If providing pain meds you must assess pain, document the pain, document the medication, and follow up with pain assessment. Correct the MAR if error, Notify DON/ADON if unable to complete. Record review of a facility provided policy, Abuse, Investigation and Reporting policy, dated 2001 Medpass, Revised July 2017 ; revealed in part: All reports of resident abuse, neglect, exploitation, misappropriation of resident property shall be promptly reported to local, state, and federal agencies. Facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect.: FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 4 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the notice of discharge or transfer was made by the facility at least 30 days before the residents transfer or discharge for 1 (Resident #1) of 2 residents reviewed for transfers/discharges. The facility failed to provide at least 30 days' notice before transferring Resident #1's to an unlicensed facility. This failure could affect residents at the facility by placing them at risk of being transferred/discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings include: Record review of Resident #1's face sheet dated 2/6/24 revealed a [AGE] year-old female resident admitted to the facility originally on 10/26-2023 and readmitted on [DATE] with diagnoses to include anoxic brain damage (death of brain cells due to complete lack of oxygen), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), Bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (Persistent depressed mood), anxiety disorder (group of mental illnesses that cause constant fear and worry), epilepsy (disorder that causes abnormal brain function, seizures), paraplegia (paralysis of the legs), colostomy (opening in the abdomen, changing the way waste exits the body) paraplegia (acquired absence of right leg below knee), obstructive and reflux uropathy (passage of urine blocked by obstruction in urinary tract), neuromuscular dysfunction of bladder (when the nerves and muscle of the bladder do not function together adequately)., Record review of Resident #1's last MDS assessment reflected a quarterly MDS completed 2-01-24 revealed a BIMS of 15 indicating cognition is intact. Record review of Resident #1's care plan dated of 10-27-23 and 1/30/24 documented the following: Focus area: initiated on 10/27/23 and canceled on 1/31/24, revealed resident required discharge planning; Resident #1 being discharged to: Plans to remain in this facility. Resident #1 to possible move to assisted living in the future. Goal area: initiated on 10/27/23 and cancelled on 1/31/24 with a target date of 4/23/24; Resident to express satisfaction with care provided by staff in this facility and will enjoy remaining in this facility through next review date. Interventions area: initiated on 10/27/23, Revised and Canceled on 1/31/24; explain methods of monitoring resident's status, stress importance of reporting emergency of complications. Explore alternative care options with resident and family. Discuss benefits and options to placement settings. Resident desired to remain in the facility and receive assists with care. Record review of the facility provided Notice of Discharge for Resident #1, dated 1/4/24 revealed, the right to appeal discharge decision information and contact information. Resident #1 was hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 5 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few delivered a copy of the discharge/transfer notification that read in part: Discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs. The resident's clinical or behavioral status endangers the safety of individuals in the facility. The resident's clinical or behavioral status endangers the health of individuals in the facility. Record Review of the facility provided letter to Resident #1 signed and dated on 1/4/24 by Resident #1, ADM and SW revealed, This letter states that Resident #1 has been provided with a Notice of discharge today 1/4/24. Resident #1 acknowledges and understands the reasons for discharge, which are listed on the Notice of Discharge. Resident #1 understands that this facility will work diligently directly with her to ensure that placement is found. Resident #1 understands that 2/4/24 will be her last day residing in this facility. Resident #1 will be provided with local resources to ensure her safety. Resident #1 will be provided a copy of this signed form. I (Resident #1 name) understand and acknowledge receipt of the Notice of Discharge. By signing this form (Resident #1) understands that she must continue to follow facility rules which were provided to her when admitted to the facility. Record Review of Resident #1's late entry Social Services Progress Note written by SW; effective date 1/29/24 at 3:02 p.m.; Created date: 2/5/24 5:10 p.m., revealed: This writer sent a referral to ALF via email after conversation with ALF owner. ALF owner stated that they have two homes available that the one off 101 places have two bedrooms, and the other home has one bedroom located off 9th. This writer stated that either or will work. 3:45 p.m.: This writer followed up with the referral sent. ALF owner stated that she needs to speak with someone regarding the funding. This writer stated that she will give the BOM her number so they can discuss financials. 4:00 p.m.: This writer contacted Alf owner to follow up with the referral. Alf Owner stated that they will accept (Resident #1). This writer stated that she will speak with Resident #1 to see when she would like to discharge. 4:30 p.m. This writer spoke with (Resident #1) who stated she would like to leave today. This writer contacted ALF Owner to notify that (Resident #1) wanted to leave today. Alf Owner stated that is fine as long as she arrives to the home located at (101st Place) before 6 p.m. This writer thanked her and ended the call. 6:00 p.m. This writer sent PASSR via email for Resident #1). Record Review of Resident #1's progress note written by LPN/LVN effective date 1/29/24 at 5:57 p.m. revealed: Resident discharged to (assisted living), left via wheelchair with facility transportation (Transportation aide). Resident is stable with vital signs within normal limits, no s/s of distress noted. All personal belongings with resident as well as medications. Record Review of the facility provided Admission/Discharge to/from report dated 2/6/24 for date range: 12/1/23-2/6/24 revealed the following: Resident #1 was discharged to assisted living on 1/29/24 and admitted back to the facility on 1/30/24. Recored Review of Resident #1's progress notes dated from 1/29/24-1/31/24 did not reveal any issues regarding the care of the ostomy and catheter or signs of infections. During an interview on 2/6/24 at 9:10 a.m. the ADM stated that Resident #1 is verbally abusive to staff and was provided a 30-day discharge notice. The ADM stated that the facility had looked for other locations but when they review the progress notes and behaviors, they refuse to take her. The ADM stated that no one will take her. The ADM stated that the facility SW contacted the ALF and stated that they would accept Resident #1. The ADM stated Resident #1 was transferred to the ALF by the SW and transportation with no issues. The ADM stated that on 1/30/24 she had been in meetings all day and had missed several calls from the ALF. She stated that as she was getting ready to leave for the day, after 5 p.m., the ALF owners came and returned Resident #1 to the NF. The ADM stated that there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 6 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were emails confirming that Resident #1 was accepted by the ALF and she would obtain them from the SW. The ADM stated that when the ALF owners brought Resident #1 back, they stated that they were private pay only and did not take Medicaid. The ADM stated that Resident #1 was admitted back to the NF, and they are looking for alternative placement for her. During a phone interview with the ALF HR on 2/6/24 at 10:04 a.m., they stated that on 1/29/24 the NF sent a referral that included medical records to the ALF Owner before 5 p.m. The ALF HR stated that the ALF Owner forwarded her the email documents for her to review for admission. The ALF HR stated that she leaves for the day at 4 p.m. and did not receive or review those emailed documents until 1/30/24. The ALF HR stated she had visited the NF in the past and spoke to the ADM and advised the ADM of the services they offered at the ALF and that they were only private pay. The ALF HR stated that on 1/30/24 she was notified that Resident #1 was dropped off at the ALF on 1/29/24 around 8 p.m. The ALF HR stated that the NF never advised the ALF owner that Resident #1 was only Medicaid. The ALF HR stated that on 1/30/24 she attempted to contact the NF ADM and NF SW several times via phone and never received a return call. The ALF HR stated that the NF SW told the ALF HM that she would return the next day (1/30/24) to complete the admission paperwork. The ALF HR stated that the facility did not contact them on 1/30/24 and after reviewing the documents sent after 4 p.m. on 1/29/24 it was determined that Resident #1 was Medicaid pay and not Private pay and that Resident #1 would lose her benefits if she was not residing in the NF. The ALF HR stated that the owners returned Resident #1 back to the NF around 4:30 p.m. on 1/30/24 and the NF ADM accepted her back after it was explained that the ALF did not accept Medicaid. The ALF HR stated that Resident #1 was dropped off after business hours because they knew that the documents had not been reviewed and they were trying to get rid of Resident #1. During an interview on 2/6/24 at 4:06 p.m. with NF SW, stated Resident #1 was provided a notice of discharge on [DATE]. The SW stated that Resident #1 can be verbally aggressive to staff and other residents and did not follow facility rules. The SW stated that Resident #1 stated she would like to live in an assisted living. The SW stated that she found an ALF facility and emailed Resident #1's face sheet, progress note and medications to the ALF owner. The SW stated that the ALF owner requested the financial and funding information for Resident #1 and the number to the NF business office manager was provided to the ALF owner. The SW stated that there was never a confirmation via email that the ALF accepted Resident #1. The SW stated she spoke to the ALF owner after 4:30 p.m. that day and was told that she could bring Resident #1 to the ALF between 5:30 p.m. -6:00 p.m. The SW stated that Resident #1 was informed, and her personal items were packed. The SW stated that Resident #1 was transferred via the facility van and the SW and Transportation driver brought Resident #1 to the ALF. The SW stated when they arrived to the ALF, the transportation driver assisted Resident #1 off the van and the SW went to the ALF door. The SW stated that a female staff answered the door and stated she was aware that Resident #1 was coming. The SW stated that the female staff stated that there was no bed in the available room and that the ALF would find her one for the night. The SW stated that Resident #1 was brought into the home and that there was not any paperwork signed. The SW stated that there was no admission or transfer paperwork completed. The SW stated that she did not work on 1/30/24 when Resident #1 was returned to the facility. The SW stated she took a photo of the ALF home from the van before they returned back to the NF. The SW opened her cell phone photographs and an image time/date stamped of the ALF home was 1/29/24 at 5:57 p.m. During a phone interview on 2/7/24 at 9:12 a.m. the Ombudsman, stated she had received a 30-day discharge notice for Resident #1. She stated that the NF discharged Resident #1 to an ALF that was private pay on 1/30/24 and dropped her off at the ALF and left. She stated that the ALF returned Resident #1 on 1/30/24 to the NF because they did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 7 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few accept Medicaid and were only private pay. She stated that the NF needed to find an appropriate placement for Resident #1 that could meet her medical needs and accepted Medicaid. The Ombudsman stated they are in the process of filing an appeal to the Notice of Discharge to ensure that the NF finds an appropriate placement to meet the resident's needs. During an interview on 2/7/24 at 11:04 a.m. with Resident #1, stated that she never had a care plan meeting about the transfer to the ALF. She stated she was told by the SW that the ALF accepted her and asked Resident #1 if she wanted to move there. Resident #1 stated that she did want to move because the facility had issued her a discharge notice. Resident #1 stated the same day she was told about the ALF the NF staff immediately started packing her belongings up. Resident #1 stated she is her own representative, and the NF did not have her sign any discharge paperwork. Resident #1 stated that the facility was trying to dump her on another facility and did not care where they took her to just as long as the NF didn't have to deal with her anymore. Resident #1 stated that it was late in the day when the Transportation Aide and the SW drove her went with them to the ALF. Resident #1 stated there were no transfer paperwork, the ALF did not have a bed for her and had to find one. Resident #1 stated that the ALF had no idea that she used a power wheelchair, ostomy bag(used to collect feces on outside of body) or amputated leg. Resident #1 stated that it was not until the next morning on 1/30/24 that the ALF found out that she had Medicaid and was not private pay. Resident #1 stated that the ALF could not provide the care she needed due to her medical needs. Resident #1 stated the ALF doorways were not big enough for the wheelchair to get through inside the house and there was no ramp to get into the home. Resident #1 stated the SW dropped her off at the door of the ALF and left her there. Resident #1 stated that she thought that the NF SW had completed all the transfer paperwork but had not. Resident #1 stated that on 1/30/24 the ALF returned her to the NF and the NF ADM argued with the ALF owner. Resident #1 stated that the NF ADM had advised her that she needed to find a place to live and to save money up for a hotel. Resident #1 stated she only gets about $35 per month and that it is not enough for a hotel room. Resident #1 stated that she is afraid the NF will put her out on the streets. During an interview on 2/7/24 at 12:25 p.m., the ADM stated that there were no emails confirming the acceptance of Resident #1 to the ALF. During an interview on 2/7/24 at 1:39 p.m. the NF Transportation Aide stated that on 1/29/24 the NF SW told her that Resident #1 was being transferred to the new facility. The NF Transportation Aide stated that Resident #1's belongings were packed and the NF SW, Resident #1 and herself left for the new facility. The NF Transportation Aide stated she assisted Resident #1 off the van in her electric wheelchair and the SW went to the ALF door. The NF Transportation Aide stated no paperwork was brought to the ALF and no paperwork was completed at the ALF. The NF Transportation Aide stated that the ALF HM and herself had to lift Resident #1's electric wheelchair to get inside the home because there was no ramp to get into the home. The NF Transportation Aide stated they went inside and were advised that a bed was needed for Resident #1. The NF Transportation Aide stated the ALF HM stated they do not provide one but would make it work for the evening. The NF Transportation aide stated they brought Resident #1's items were brought into the home and the NF SW and herself left and returned back to the NF. During an interview on 2/7/24 at 1:48 p.m. with the NF Business Manager; stated that she only had one conversation with the ALF owner after the NF SW notified her that the ALF owner wanted to talk about Resident #1's finances. The NF Business Manager stated that the ALF owner asked for the Mesav that documented the benefits for Resident #1 to be emailed to her. The NF Business manager stated that this occurred on 1/29/24 and it was almost 5 p.m. The NF Business Manager stated she notified the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 8 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few NF SW that the ALF would accept Resident #1 and advised the NF SW to contact the ALF Owner to discuss the transfer information. The NF Business manager stated that there was no email from the ALF owner to confirm that Resident #1 had been accepted to the ALF. The NF Business manager stated that the NF SW advised that the transfer occur the next day on 1/30/24. The NF Business manager stated she advised the ALF Owner that Resident #1 was on SSI and private pay was never discussed. The NF Business manager stated that the transfer process is to send a referral packet to the potential facility and then there is a call to determine if the resident is accepted and transportation is arranged. The NF Business Manager stated that when a Resident arrives to the new facility the resident is documented as discharged in the system and an admission packet is completed at the new facility. During an interview on 2/12/24 at 10:53 a.m. with the ALF HM, stated that ALF owner notified her that they may be possibly admitting a new Resident to the home. The ALF HM stated that the NF SW brought Resident #1 to the ALF home on 1/29/24 at approximately 8 p.m. and did not fill out or provide any paperwork. The ALF HM stated that the home does not typically provide a bed for residents and had to get a temporary bed out of storage for Resident #1. The ALF HM stated she was not aware of the extensive medical needs that Resident #1 needed or that Resident #1 had a colostomy bag, catheter and had a leg amputation limiting the Resident's ability to perform her own ADL's. The ALF HM stated that the SW brought Resident #1 to the door, handed off Resident #1's medications and did not provide any documentation for the transfer nor was an admission packet completed or provided. The ALF HM stated she immediately notified the ALF owner that Resident #1 was in the home and the assistant HM assisted in locating a bed frame, box spring and a blow-up mattress for the Resident to sleep. The ALF HM stated that the next day, Resident #1 was returned to the NF because the ALF had not accepted the admission due to Resident #1. The ALF HM stated that the ALF is private pay only and did not accept Medicaid residents. The ALF HM stated that they could not provide the medical needs that Resident #1 required. During an interview on 2/12/24 at 11:00 a.m. the ALF Assistant HM, stated that on 1/30/24 he notified the ALF owner that Resident #1 was on Medicaid and not Private Pay. The ALF assistant HM stated that the ALF owner stated that they had not approved Resident #1 for admission and had no admission paperwork for Resident #1 nor did the NF inform her that the resident was on Medicaid. The ALF assistant HM stated that he called the Medicaid provider who advised him that Resident #1 would lose her benefits if Resident #1 was not in the NF. The ALF assistant HM stated that they attempted to reach the NF ADM via telephone with no contact and they returned Resident #1 back to the NF on 1/30/24. The ALF assistant HM stated that the NF ADM was upset that the ALF would not keep Resident #1 and ultimately, the NF readmitted Resident #1 into their care and services. During an interview on 2/12/24 at 11:15 a.m. the ALF owner, stated that on 1/29/24 the NF SW had contacted her to see if the ALF had room for a new admission. The ALF owner stated that she repeatedly told the SW that the ALF was private pay and requested the financial information and medical information from the SW for Resident #1. The ALF owner stated the NF SW stated that she would notify the NF business manager that the items were requested. The ALF owner stated that the NF SW emailed her medical documents, but it was after 4 p.m. and the ALF HR person was already out of the office for the day. The ALF Owner stated she advised the NF SW that the ALF HR person would need to review the documents and when she received them from the NF SW, she forwarded the email to the ALF HR person. The ALF Owner stated that during the call with the NF SW she was advised that the facility would like to transfer Resident #1 the following day. The ALF owner stated she never spoke to the NF business manager and the SW called her approximately 10 minutes later on 1/29/24. The ALF owner stated that the NF SW stated that ALF never provided an acceptance letter for the transfer. The ALF owner stated that when the NF SW (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 9 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few called her back, she stated that the NF was bringing Resident #1 now to the ALF. The ALF owner stated that she had no knowledge of the medical needs that Resident #1 had and was not aware that Resident #1 had a colostomy bag, catheter, or amputated leg. The ALF owner stated that she had only been informed by the NF SW that Resident #1 needed assistance but was not aware of the level of assistance Resident #1 needed. The ALF owner stated she advised the NF SW several times that the ALF was private pay only and stated that the NF SW stated okay. The ALF owner stated she felt that Resident #1 would be without a place to stay that evening because the NF was immediately bringing Resident #1 to the ALF. The ALF owner stated she advised the NF SW what home had an opening and said okay when the NF SW stated they were on the way to drop off Resident #1. The ALF owner stated it was not until 1/30/24 that the ALF realized that Resident #1 was not private pay and had Medicaid. The ALF owner stated that the ALF did not know there was such medical care needed for Resident #1 until Resident #1 was dropped off at the ALF door. The ALF owner stated the NF dumped Resident #1 at the ALF and was aware that the ALF did not accept private pay. The ALF owner stated that on 1/30/24 after several unsuccessful attempts to reach the NF ADM, they brought Resident #1 back to the NF. The ALF owner stated that Resident #1 called her a few days ago (date unknown) and stated that the NF ADM was going to kick her out and that the NF ADM stated Resident #1 needed to get a hotel room. The ALF owner stated she felt bad for Resident #1 but due to Resident #1's medical needs and that she had Medicaid and could not private pay, the ALF could not accept her as a resident. The ALF owner stated she had never had a NF, or any other agency drop a resident off without admission paperwork completed for Resident #1. The ALF owner stated the NF SW had been aware that the ALF HR person was not available to review the documents to approve the transfer. The ALF owner stated that had Resident #1 been admitted to the ALF under Hospice care with Private Pay, Hospice would of provided a nurse or CNA to perform the medical duties associated with the catheter and colosomy bag. Record review of the facility provided policy titled, Transfer or Discharge Notice, Preparing a Resident for 2001 Medpass, revised December 2016, revealed the following: Policy Statement: Resident will be prepared in advance for discharge. Policy Interpretation and Implementation: 1. When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. 2. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. 3(j). Directing the resident or representative(sponsor) to the business office prior to the transfer or discharge. 4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: d. An immediate transfer of discharge is required by the resident's urgent medical needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 10 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for the care and treatment of 1 of 1 facilities reviewed. Residents Affected - Many The facility failed to employ a DON. This failure had the potential to place residents in the facility at risk by leaving staff without supervisory coverage and could place residents at risk for inconsistency in care and services. Findings included: Record review of the facility's computer-generated time sheets revealed the last day of the previous Director of Nurses' employment was 12/11/2023. During an interview on 2/6/24 at 8:06 a.m., the ADM stated that the facility's last DON quit in December 2023 and the facility had a consulting nurse was the facility interim DON since the DON quit. During an interview on 2/6/24 at 10:49 a.m., the ADON stated that the facility did not have a DON and the last time there was a DON was in December 2023. During an interview on 2/6/24 at 12:06 p.m., the consulting nurse stated that the previous DON quit in December 2023. The Consulting nurse stated she had previously been employed as the DON for the facility, but she had not performed DON duties nor was she the interim DON for the facility. The DON stated she did not work full time at the facility. The Consulting nurse stated that when the facility needs her assistance, she comes but does not fulfil any DON duties on a full-time basis and is at the facility maybe 40 hours per month. The Consulting nurse stated she worked for corporate and traveled as a consulting nurse around to different states. Record review of the undated facility provided position description for Director of Nursing, revealed the following job summary in part: He/she plans, organizes, coordinates and directs all the nursing functions for professional and nonprofessional nursing personnel to ensure the highest quality of care is provided. Responsibilities include, in part: maintains accurate reporting and recording according to policies and procedures; Responsible for assuring accurate recording of medications and narcotics; conducts orientation and educational programs for nursing personnel . Record review of the undated facility provided policy titled Director of Nursing (absence of), revealed in part: POLICY Statement: Shall employ a fulltime Director of Nursing. In the brief absence of Director of Nursing, it's facilities shall ensure that an RN is scheduled each day. (Corporate name) also provided an experienced RN consultant that is available to its staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 11 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all medications for 2/4 medication carts reviewed for pharmaceutical services in that: LVN A failed to sign the narcotic count sheets for 2/4 medication carts (North 3 Medication aide and North 3) reviewed for change of custody at shift change. MA failed to sign the narcotic count sheet for 1 of 2 (North 3 Medication aide) carts reviewed for change of custody at shift change from LVN A. The facility failed to ensure LVN B, LVN C, RN followed the physician's orders for Resident #2's PRN pain medication administration for Norco 5-325 mg. These failures could place residents at risk of having their medications diverted or missing. Findings include: Record review of North 3 cart and Medication Aide 3 cart showed that LVN A did not sign the Narcotic Count sheet on 2/3/24, 2/4/24 and 2/6/24 to take responsibility of the cart at the start of the 6 a.m. shift. Record review of Medication Aide 3 cart showed that MA did not sign the Narcotic Count sheet on 2/6/24 when he took responsibility of the cart from LVN A. Record review of the North 3 Medication Aide cart Narcotic Count Sheet showed that on 2/2/24 no signature was made by the 6am-6pm when the cart was signed by the incoming nurse(LVN A) and offgoing nurse (LVN B) on the 6pm-6 a.m. shift . During an interview on 2/6/24 at 8:15 a.m. with the ADM stated that the facility self-reported a medication diversion after it was discovered that Resident #2's Norco's were not being given correctly or documented in the MAR/EMAR. The ADM stated that during the facility investigation, the facility was drug testing the nurses and medication aides who had access to the carts that had Resident #2's medications in them. The ADM stated that the RN came to her and stated that he took one of Resident #3's Hydro pain pills because he was having knee and back pain. The ADM stated that the RN documented he removed the pill from Resident #3's narcotic count sheet but did not put in in the MAR that he administered it to Resident #3. The ADM stated that the RN was suspended, and she attempted to call him, but he did not return her call. The ADM stated that it was determined during the investigation that LVN B had been documenting that she removed 2 tabs from Resident #2's narcotic count sheet but had not put it in the MAR that it was administered. The ADM stated that Resident #2's orders are for 1 tab of 5/325 mg and LVN B was signing out 2 tabs of 5/325 mg. The ADM stated that Resident #2 cannot state whether she received the medication or not and it is also not in the MAR, so the facility was unable to determine if Resident #2 received the Norco. The ADM stated that LVN B tested negative, and Resident #2 tested positive for the narcotic. The ADM stated that staff are trained on how to properly document and administer medications. During an interview and record review on 2/6/24 at 10:49 a.m., the ADON provided a copy of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 12 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some current sign on sheet for the MA3 cart when it was identified that the oncoming staff, LVN A did not sign the book to take responsibility of it. The ADON stated that staff must sign onto the cart narcotic count sheet to take ownership of the keys and confirm that all medications are accounted for. The ADON stated that this should be monitored by the facility DON and the DON should perform the training, but there is not a DON. During an interview with MA on 2/6/24 at 11:37 a.m., he stated that he did not sign for the MA 3 cart when he started his shift this morning. The MA stated that LVN A took responsibility of the cart at 6 a.m. and the MA was handed the keys when he arrived prior to 6:30 a.m. The MA stated he had been trained to sign onto the cart and was trained to sign out medications from the cart but failed to sign onto the cart. The ADON stated had LVN B, LVN C and the RN followed proper policy they would have checked the MAR to verify the order, completed a pain assessment and then logged on the controlled substance log that they pulled the medication, administered, and logged the medication into the MAR. During an interview with LVN A on 2/6/24 at approximately 11:42 a.m., LVN A confirmed that he did not sign onto the North 3 Cart or the Medication Aide 3 cart when he took the keys from the overnight LVN at 6 a.m. LVN A stated he did count the cart to confirm accuracy but failed to sign for both carts. LVN A stated that when the MA arrived, he did not perform a count of the cart with the MA and handed the keys to the MA. LVN A stated that neither he nor the MA counted the cart before responsibility was transferred to the MA. LVN A stated he made a mistake and had been trained to sign for the carts after confirming accuracy of the count . LVN A stated that the purpose of performing a count and signing on/off the medication cart is to that there is a risk that the medication count could be inaccurate due to medication diversion, theft or missed documentation of administration to residents. LVN A stated that unaccounted for medications could place residents at risk of not getting their medications. During an interview with the Corporate Liaison on 2/6/24 at 11:45 a.m., they stated that the nurses and medication aides are never to sign onto the medication carts without counting the narcotics and signing onto the carts . The Corporate Liaison stated that the risk of not counting or signing onto the carts could be drug diversion and missing medications. The Corporate Liaison stated that if the facility had a DON, the DON would be in charge of ensuring that staff were trained and monitored to sign and document transfer of the medication carts. During an observation of the North 3 and Medication Aide 3 carts on 2/6/24 at approximately 11:46 a.m., a complete count of all narcotics were completed by the ADON, Corporate Liaison, LVN A and MA with no missing medications. During an interview on 2/6/24 at approximately 5:00 p.m. LVN B stated that she worked the 6 p.m. to 6 a.m. shift. LVN B stated that she had been administering 2 tabs of 5/325mg Norco to Resident #2 because that is what the old order stated. LVN B stated that she did not log in the MAR that she administered Resident #2's Norco but stated she did give them to Resident #2. LVN B stated that she gave Resident #2 the medication and she did not take any medications from any resident. LVN B stated that she had been trained how to administer medications. LVN B stated she did not know how she missed completing the pain assessment, post pain assessment or documenting that she administered in the MAR. LVN B stated she had personal issues and lost her home and had been very stressed and had not been thinking clear. LVN B stated that she had been a nurse for over 20 years and had been trained on the Rights of Medication Administration. LVN B stated that she did log and remove 2 tabs of Norco off of Resident #2's-controlled log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 13 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a telephone interview on 2/7/24 at 2:27 p.m. LVN C stated that Resident #2 received Norco for a PRN (as needed) pain medication. LVN C stated that she never checked the order in the MAR and went by memory of what she was supposed to administer to Resident #2. LVN C stated she would sign out from the controlled logbook 2 Norco tabs for Resident #2 and would give them to Resident #2. LVN C stated she did not check the MAR to confirm the correct dose or if the medication was a current order. LVN C stated that she did not document a pain assessment as required in the MAR. LVN C stated she had been a LVN for 21 years and had been trained to review the order in the MAR, complete a pain assessment and to complete another assessment about an hour after the resident received the pain medication to determine if it had been effective. LVN C stated that if it's not documented in the MAR then I didn't verify the order. LVN C stated that she did not follow the policy or procedures on giving a pain medication to Resident #2 and that I messed up, so I did wrong. LVN C stated that there is a risk of a Resident getting too much or too small of a dose by not checking the order or that the order is not current. An attempted phone interview with RN was made on 2/7/24 at 1:44 p.m., phone was disconnected. Confirmation of phone number from facility ADM and facility records was made. A certified letter was mailed to RN on 2/12/24 with request for RN to contact HHSC Investigator via telephone. In-service on 1/26/24 for LVN B revealed summary of training session: No meds/treatments may be administered without a physician order. If providing pain meds you must assess pain, document the pain, document the medication, and follow up with pain assessment. Correct the MAR if error, Notify DON/ADON if unable to complete. Record Review of the Facility provided policy, Documentation of Medication Administration dated 2001 Med-Pass (revised April 2007 revealed: Policy Statement: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A nurse or certified medication aide shall document all medications administered to each resident on the resident's medication administration record (MAR) 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include at a minimum: Name and strength of drug, Dosage, Method of Administration, Date and time of Administration, Reason(s) why a medication was withheld, not administered, or refused. Signature and title of the person administering the medication and Resident response to the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 14 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Record Review of the Facility provided policy, Administering Pain Medications dated 2011 Med-Pass (revised October 2010) revealed: Purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. Residents Affected - Some Steps in the Procedure: Conduct a pain assessment; administer pain medications as ordered; Document the results of the pain assessment, medication, dose, route of administration and results of the administration. Record Review of the facility provided Disciplinary Action Form dated 2/6/24 for MA revealed the following: Nature of Offense: Accepted medication cart/narcotics without counting the narcotics. Action taken: Verbal Warning. Signed by Corporate Liaison and MA. Record Review of the facility provided Disciplinary Action Form dated 2/6/24 for LVN A revealed the following: Nature of Offense: Did not sign the narcotic reconciliation today (2-6-24). If the sheet was not signed it was not done. Action taken: Verbal Warning. Signed by Corporate Liaison and LVN A. Record review of the undated facility provided position description for Director of Nursing, revealed the following job summary in part: He/she plans, organizes, coordinates, and directs all the nursing functions for professional and nonprofessional nursing personnel to ensure the highest quality of care is provided Responsible for assuring accurate recording of medications and narcotics; conducts orientation and educational programs for nursing personnel. Review of facility provided policies: Controlled Substances-2001 Medpass, revised December 2019; The facility complies with all laws, regulations, and other requirements related to handling, storage and disposal and documentation of II and other controlled substances. -Controlled substances are reconciled upon receipt, administration, disposition and at the end of each shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 15 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for 2 of 2 residents (Resident #2 and #3) whose records were reviewed for medication administration. The facility failed to completely and accurately document administration of a PRN pain medication to Resident #2 by not documenting Hydrocodone-Acetaminophen (Norco) 5-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever) in the MAR. The facility failed to completely and accurately document administration of medication to Resident #3's Hydrocodone-Acetaminophen (Norco) 7.25-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever). This failure could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings Included: Record review of Resident #2's face sheet dated 1/25/24 indicated Resident #2 was a [AGE] year-old female who admitted on [DATE] with the following diagnoses: Cerebral Infarction(stroke), Angina pectoris(chest pain), muscle weakness, dementia(cognitive loss), pain in unspecified joint, rheumatoid arthritis(autoimmune inflammation of the joints). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed that a BIMS was not conducted due to resident is rarely/never understood. Record Review of Resident #2's Medication Order received by ADON revealed on 12/27/23 an order for Hydrocodone-Acetaminophen Oral Tablet 5-325mg; Give 1 tablet every 4 hours for pain. Record Review of Resident #2's Medication Order received by LVN B revealed on 9/10/23 an order for Hydrocodone-Acetaminophen Oral Tablet 10-325mg; Give 1 tablet every 4 hours for pain. Record Review of Resident #2's Medication Order received by DON (prior) revealed on 8/30/23 an order for Hydrocodone-Acetaminophen Oral Tablet 5-325mg; Give 1 tablet every 4 hours for pain. Record Review of Resident #2's Medication Administration Record (MAR) from 1/1/24-1/25/25 documented no administration of Norco to Resident #2 and no pain assessment completed. Record Review of Resident #2's Controlled Substance Record documented Resident #2 received 2 tabs of 5/325 mg Norco 32 times from 1/1/24-1/25/24 that were signed out by LVN B, LVN C and RN with no pain assessments completed. Record Review of Resident #2's Controlled Substance Disposition Record for Norco Tab 5-325, Take 1 tablet by mouth every 4 hours as needed for pain revealed: -LVN B signed out 2 tabs on the following dates and times: 1/23/24 3:46 a.m., 1/23/24 6:40p.m., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 16 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 1/23/24 11:46 p.m., 1/24/24 6:43 p.m. and 1/14/24 at 11:50o.m. Level of Harm - Minimal harm or potential for actual harm -RN signed out 2 tabs on 1/11/24 at 12:00 p.m. Residents Affected - Few Record Review of Resident #3's face sheet dated 1/25/24 revealed Resident #3 is a [AGE] year-old male, admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction(stroke), Hemiplegia and Hemiparesis affecting left side(partial paralysis following stroke), Chronic Obstructive Pulmonary Disease(COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), Psoriatic arthritis(type of arthritis linked with psoriasis, a chronic skin and nail disease), Rheumatoid Arthritis(autoimmune inflammation of the joints), Pain in left leg. Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 that indicated cognitively intact. Record Review of Resident #3's Controlled Substance Disposition Record and order for Hydroco/Apapa(Norco) Tab 7.5-325, Take 1 tablet by mouth every 6 hours as needed for pain revealed that RN signed out 1 tag on 1/25/24 at 8:00 a.m. Record Review of Resident #3's MAR for 1/25/24 revealed that Resident #1 was administered Norco 7/5/325 mg oat 01:40 a.m. and revealed no documented administration at 8:00 a.m.by RN. Record review of the ADM's timeline of events and screenshots of camera footage, signed and dated by the ADM on 2/7/24 revealed the following in part: 2/7/24: ADM at (Facility name) reviewed videos on [NAME] for Resident #2 room from the phone of Resident #2's FM, Upon reviewing the videos this is what I concluded: On 1/11/24 RN signed out a Norco 325 at 12 p.m. for Resident #2. After reviewing the video RN did not administer any medication to Resident #2, RN entered the room around 1:30 pm. only to look at Resident #2's catheter. On 1/23/24 LVN B signed out a Norco 325 at 0346, 1840 and 2346 for Resident #2. After reviewing the video LVN B did not administer medication at 0346 or 2346. On 1/24/24 LVN B signed out Norco 325 at 1830 and 2350 for Resident #2, LVN B did not administer the medication at 2350. On 1/31/24 LVN B signed out Norco 325 at 1905 and 2345 for Resident #2, LVN B administered the medication at approximately 1930 and did not administer medication at 2345. During an interview on 2/6/24 at 8:15 a.m. the ADM stated that the facility self-reported a medication diversion after it was discovered that Resident #2's Norco's were not being given correctly or documented in the MAR/EMAR. The ADM stated that during the facility investigation, the facility was drug testing the nurses and medication aides who had access to the carts that had Resident #2's medications in them. The ADM stated that the RN came to her and stated that he took one of Resident #3's Norco pain pills because he(RN) was having knee and back pain. The ADM stated that the RN documented he removed the pill from narcotic count sheet but did not put in in the MAR that he administered it to. The ADM stated that the RN was suspended, and she attempted to call him, but he did not return her call. The ADM stated that it was determined during the investigation that LVN B had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 17 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documenting that she removed 2 tabs from Resident #2's narcotic count sheet but had not put it in the MAR that it was administered. The ADM stated that Resident #2's orders are for 1 tab of 5/325 mg and LVN B was signing out 2 tabs of 5/325 mg. The ADM stated that Resident #2 cannot state whether she received the medication or not and it is also not in the MAR, so the facility was unable to determine if Resident #2 received the Norco. The ADM stated that LVN B tested negative, and Resident #2 tested positive for the narcotic. During an interview on 2/6/24 at 9:06 a.m. the Corporate Liaison, stated that the facility identified an issue with the count sheet for Resident #2 that showed the nurses were signing out 2 tabs of Norco 5/325mg instead of 1 tab. The Corporate Liaison stated the Hospice had contacted the ADON about Resident #2 because LVN B had requested refills for Resident #2's Norco prescription but had told Hospice that the order was for 10/325 mg and not 5/325mg. The Corporate Liaison stated that was what started the investigation and self-report and during the investigation they were drug testing all the nurses who had access to the medication carts. The Corporate Liaison stated that the RN stated he would test positive because he took one of Resident #3's Norco's on 1/25/24 because he had leg or back pain. The Corporate Liaison stated that LVN B tested negative for any controlled substances. The Corporate Liaison stated the RN confessed that he took one of Resident #3's pain meds. The Corporate Liaison stated that Resident #2's Norco's were signed out of the controlled substance logbook but never documented in the MAR by the nurses. The Corporate Liaison stated that when the ADON received the new order for Norco for Resident #2 on 12/27/24 the ADON put the order in the Nurse MAR and not the Standard MAR which prevented the order the MAR for administration of the medication. The Corporate Liaison stated that the MAR automatically puts the order into the nurse MAR instead of the Standard MAR and the ADON was not aware of this. The Corporate Liaison stated that from 12/27-23-1/25/24 RN, LVN B and LVN C did not document administration of Norco to Resident #2 and never notified the ADON of the missing order. The Corporate Liaison stated that Resident #2 tested positive for the Norco but that the test does not state how much was in her system or how long the medication had been in her system. The Corporate Liaison stated she would provide the MAR. The Corporate Liaison stated that nurses are trained to look into the MAR for an order of pain medication, document and complete the pain assessment, verify the medication and dose is correct and then go to the locked PRN medication cart to verify the count of the medication, pull the correct dose, document the updated count and then administer the medication per the order to the resident. The Corporate Liaison stated that then the nurse would go back into the MAR to document the effect if any the pain medication had on the resident pain in another assessment. The Corporate Liaison stated that had the RN, LVN B or LVN C completed those steps they would had noticed that the MAR was not updated with the order, and they could have updated the order in the MAR. During an interview on 2/6/24 at approximately 5:00 p.m. LVN B stated that she worked the 6 p.m. to 6 a.m. shift. LVN B stated that she had been administering 2 tabs of 5/325mg Norco to Resident #2 because that is what the old order from before August 2023 stated. LVN B stated that she did not log in the MAR that she administered Resident #2's Norco but stated she did give them to Resident #2. LVN B stated that she gave Resident #2 the medication and she did not take any medications from any resident. LVN B stated that she had been trained how to administer medications and would never steal from a resident. LVN B stated that when a resident stated they are in pain, she was to look in the MAR for an order, complete the pain assessment and progress note and then check the PRN locked medication cart for the medication that is in the MAR to verify the medication and dose. LVN B stated she would then have to check the previous documented amount left and document how many tablets she pulled from the card, update the card number and then administer the medication to the resident. LVN B stated she should have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 18 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few then documented the administration in the MAR and approximately one hour later complete and document a post pain assessment in the MAR. LVN B stated she did not complete a pain assessment or post pain assessment in the MAR. LVN B stated that she had not been aware until 1/25/24 that the MAR did not have Resident #2's Norco order in the system. LVN B stated she did not know how she missed completing the pain assessment, post pain assessment or documenting that she administered in the MAR. LVN B stated she had personal issues and lost her home and had been very stressed and had not been thinking clear. LVN B stated that she had been a nurse for over 20 years and had been trained on the Rights of Medication Administration. LVN B stated that she volunteered for a drug test, and it was negative so it's not that big of a deal because if she was negative, it meant that she was not taking Resident #2's medication. LVN B stated that she did log and remove 2 tabs of Norco off of Resident #2's-controlled log. LVN B stated that she did modify the order on 9/10/23 from 5/325 to 10/325 Norco for Resident #2 because she felt that 1 tab did not control Resident #2's pain. LVN B stated that the facility never received 10/325 mg Norco tabs, so she wrote on the controlled log 2=10mg that meant to give 2 of the 5/325mg. LVN B stated that she did not realize that by administering 2 tabs of 5/325 she had administered 10/650mg of Norco to Resident #2. During an interview on 2/7/24 at 11:32 a.m. Resident #2 stated that she normally does not have pain and that sometimes she will ask for her night pain meds but not always. Resident #2 stated that she did not complain to the nurses at night that she was in pain and that sometimes she would get 1-2 meds at a time at night from a nurse. Resident #2 was unable to provide any further details. During an interview on 2/7/24 at 12:15 p.m. the ADM stated that she is reviewing footage from the camera that is in Resident #2's room that the family provided her. The ADM stated that she had already reviewed 4 occurrences where LVN B signed out the Norco for Resident #2 and did not give Resident #2 the medication, for a total of 7 Norco tabs. The ADM stated that she is the abuse coordinator for the facility. During an interview and observation on 2/7/24 at 1:30 p.m. with Resident #3 in the hallway he stated that he never had a problem getting his pain medications in the past and that he was aware that the RN took one of his pain medications. Resident #3 stated he did not want to press charges against the RN because he liked the RN and he is a pretty cool guy who made a mistake. Resident #3 stated he was not concerned about the missing Hydro pain pill. During a telephone interview on 2/7/24 at 2:27 p.m. LVN C stated that Resident #2 received Norco for a PRN (as needed) pain medication. LVN C stated that she never checked the order in the MAR and went by memory of what she was supposed to administer to Resident #2. LVN C stated she would sign out from the controlled logbook 2 Norco tabs for Resident #2 and would give them to Resident #2. LVN C stated she did not check the MAR to confirm the correct dose or if the medication was a current order. LVN C stated that she did not document a pain assessment as required in the MAR. LVN C stated she had been a LVN for 21 years and had been trained to review the order in the MAR, complete a pain assessment and to complete another assessment about an hour after the resident received the pain medication to determine if it had been effective. LVN C stated that if it's not documented in the MAR then I didn't verify the order. LVN C stated that she did not follow the policy or procedures on giving a pain medication to Resident #2 and that I messed up, so I did wrong. LVN C stated she did not know that the order was not in the MAR until 1/25/24 when it had been discovered by the ADON. LVN C stated it's possible I missed others when asked if she had not checked the orders for other residents prior to giving medications. LVN C stated she never wrote on the Controlled Substance log sheet that Resident #2 was to get 2 tabs and that she gave 2 tabs because it was from memory. LVN C stated that she was terminated because she refused to drug test. LVN C stated she never took any of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 19 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm #2's medications. LVN C stated that there is a risk of a Resident getting too much or too small of a dose by not checking the order or that the order is not current. An attempted phone interview with RN was made on 2/7/24 at 1:44 p.m., phone was disconnected. Confirmation of phone number from facility ADM and facility records was made. Residents Affected - Few A certified letter was mailed to RN on 2/12/24 with request for RN to contact HHSC Investigator via telephone. Record Review of the undated facility obtained written statement by RN revealed the following, On the morning of 1/25/24, I did take 1 of (Resident #3's) Norco 7.5mg/325 mg. I did so do to back and knee pain. I take full responsibility for my action which was a terrible error judgement. Signed by RN. Record Review of the disciplinary action form dated 1/25/24 for LVN B revealed: Nature of Offence: Gave Resident #2 twice the ordered amount of Hydrocodone (ordered 5-325mg) gave 2 (10-550mg) for a total of 25 doses. Signed out 50 doses of Hydrocodone but did not document in EMAR. Statement from LVN B: No one told me not to call hospice to reorder her medications or did I know about any issues. Will follow orders closely. Record review of the Provider Investigation Report dated 1/25/24 revealed: The facility self-reported a drug diversion incident that occurred on 1/25/24. The PIR documented that RN stated that he consumed 1 of Resident #3's 7.5 Norco's and that the facility reported RN to the Texas Board of Nursing and suspended the RN. The Police were contacted and interviewed the RN, but no charges could be made as the RN did not have possession of the Norco because he ingested it. Record Review of In-service on 1/26/24 for LVN B revealed summary of training session: No meds/treatments may be administered without a physician order. If providing pain meds you must assess pain, document the pain, document the medication, and follow up with pain assessment. Correct the MAR if error, Notify DON/ADON if unable to complete. Record review of a facility provided policy, Abuse, Investigation and Reporting policy, dated 2001 Medpass, Revised July 2017 ; revealed in part: All reports of resident abuse, neglect, exploitation, misappropriation of resident property shall be promptly reported to local, state, and federal agencies. Facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect. Record Review of the Facility provided policy, Documentation of Medication Administration dated 2001 Med-Pass (revised April 2007 revealed: Policy Statement: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A nurse or certified medication aide shall document all medications administered to each resident on the resident's medication administration record (MAR) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 20 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 2. Level of Harm - Minimal harm or potential for actual harm Administration of medication must be documented immediately after (never before) it is given. 3. Residents Affected - Few Documentation must include at a minimum: Name and strength of drug, Dosage, Method of Administration, Date and time of Administration, Reason(s) why a medication was withheld, not administered, or refused. Signature and title of the person administering the medication and Resident response to the medication. Record Review of the Facility provided policy, Administering Pain Medications dated 2011 Med-Pass (revised October 2010) revealed: Purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. Steps in the Procedure: Conduct a pain assessment; administer pain medications as ordered; Document the results of the pain assessment, medication, dose, route of administration and results of the administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 21 of 21