Health inspection·October 24, 2025

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's responsible party, consistent with his or her authority, when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 6 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's responsible party when Resident #1 had a medication error, change in condition, and was transferred to the hospital on [DATE]. This failure could place residents at risk of a decreased quality of life or hospitalization resulting in a decline in psychosocial or physical health.The findings included:Record review of an undated admission record revealed Resident #1 was an [AGE] year old female, admitted [DATE], with diagnoses that included Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors), fracture of the lower end of right femur (hip fracture), type 2 diabetes (a condition in which the body cannot use insulin correctly and sugar builds up in the blood) and dementia (a general term for impaired ability to remember, think, or make decisions). The admission record revealed Resident #1 had an emergency contact #1 and emergency contact #2 listed with telephone numbers and addresses. Record review of a facility document titled Brief Interview for Mental Status (BIMS) Evaluation, dated 10/17/2025, revealed a BIMS score of 03, indicating severe cognitive impairment. Record review of Resident #1's undated comprehensive care plan, revealed a care plan that stated Resident #1 had a diagnosis of Parkinson Disease with an intervention, give medications as ordered by the physician, dated 10/23/2025. Record review of an undated facility document titled, SNF/NF to Hospital Transfer Form revealed Resident #1 was transferred to the hospital for a med error at 10/21/2025 at 5:00 p.m. and the document was completed by the ADON. Record review of Resident #1's progress notes dated 10/21/2025 at 5:31 p.m., by LVN C, revealed, Patient was returning to her room after dinner and this nurse (LVN C) and staff noticed patient had altered mental status and shortness of breath. Patient was unable to hold herself up in her wheelchair. This nurse took patient to her room, administered O2 @ 2L, via nasal canula, this nurse completed a head-to-toe assessment, and this nurse immediately called [ADON]. A progress note dated 10/21/2025 at 5:45 p.m. by the ADON revealed, LATE ENTRY. Resident sent out to [hospital] via stretcher escorted by EMS per [physician] for further evaluation and treatment d/t AMS and changes in vitals. Administrator and DON informed on [sic]incident. During an interview on 10/24/2025 at 1:20 p.m., Resident #1's RP, stated the RP arrived at the nursing facility to visit Resident #1 at 10:00 a.m. on 10/23/2025 and were notified by the ADON that Resident #1 was administered five tablets at one time of her Carbidopa-Levodopa instead of following the new order, given by the NP on 10/20/2025, to give one tablet at assigned times. The RP was told Resident #1 was sent to the hospital due to a change in condition. The RP stated no one called or notified the RP or emergency contact on 10/21/2025 when Resident #1 had a change in condition and was sent to the hospital. During an interview on 10/24/2025 at 1:50 p.m., LVN C stated she Page 1 of 10 676274 676274 10/24/2025 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was the charge nurse for Resident #1 on 10/21/2025 and stated the ADON sent Resident #1 to the hospital and completed the physician notification. LVN C stated she did not call and notify the RP of Resident #1's medication error, change in condition, or transfer to the hospital because she assumed the ADON made the notification. LVN C stated, usually the nurse who sends them out, does the discharge notification and LVN C stated the shift was changing and they had another emergency going on at the same time. LVN C stated responsible parties should be notified of changes at the time of the incident. LVN C stated it was important to notify the responsible party, because something bad can happen and they need to know that their family member is not in the building and headed out to the hospital. LVN C stated she talked to the RP on the morning of 10/22/2025 and the responsible party told LVN C that the responsible party had not been notified of the medication error, change in condition, or transfer to the hospital. During an interview 10/24/2025 at 2:07 p.m., the ADON, stated he was notified by LVN C that Resident #1 had a change in condition on 10/21/2025 around 5:00 p.m. The ADON said he contacted the physician and received an order to send Resident #1 to the hospital. The ADON stated normally it was the charge nurse's responsibility to notify the responsible party at the time of a medication errors, change in condition, and transfers to the hospital. The ADON stated we had so much going on right then that there was a mishap and miscommunication and the RP was not contacted at the time of the medication error, change in condition, and transfer to the hospital. The ADON stated Resident #1's RP arrived at the facility on 10/22/2025 and was notified at that time of Resident #1's medication error, change in condition, and transfer to hospital. The ADON stated it was important to notify the responsible party of changes in order to let them know where their family member is and they need to know from us and not from the hospital. Record review of an undated facility policy titled, Discharge/Transfer of (Voluntary)the Resident, the policy stated, Transfer: 4. Explain transfer and reason to the resident and/or representative or person (s) responsible for care. Record review of a facility document dated 10/22/2025, and titled, In-Service Training: Proper Notification to Responsible Parties Following a Medication Error, stated, Immediate Actions Following Discovery of a Medication Error: 3. Notify the Responsible Party/Resident Representative: a. Must be done promptly after physician notification, especially if the error resulted in or could result in harm. 676274 Page 2 of 10 676274 10/24/2025 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 1 of 6 residents (Resident #1) reviewed for drug administration. Resident #1 was administered 5 tablets of Carbidopa-Levodopa 25-100mg on 10/21/2025 at noon. The physician order was Carbidopa-Levodopa 25-100mg give 1.5 tablets at 11 a.m. Resident #1 was transferred to the hospital on [DATE] for altered mental status. The noncompliance was identified as PNC. The facility corrected the noncompliance before the survey began.This failure could place residents at risk for not receiving a therapeutic effect or being over-medicated.The findings included:Record review of an undated admission record revealed Resident #1 was an [AGE] year old female, admitted [DATE], with diagnoses that included Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors), fracture of the lower end of right femur (hip fracture), type 2 diabetes (a condition in which the body cannot use insulin correctly and sugar builds up in the blood) and dementia (a general term for impaired ability to remember, think, or make decisions). The admission record revealed Resident #1 had an emergency contact #1 and emergency contact #2 listed with telephone numbers and addresses. Record review of a facility document titled Brief Interview for Mental Status (BIMS) Evaluation, dated 10/17/2025, revealed a BIMS score of 03, indicating severe cognitive impairment. Record review of Resident #1's undated care plan, revealed a care plan that stated Resident #1 had a diagnosis of Parkinson Disease with an intervention to, give medications as ordered by the physician, dated 10/23/2025.Record review of Resident #1's hospital Discharge summary, dated [DATE], revealed an order, Continued carbidopa-levodopa 25-100mg tablet. 5 tab PO daily. Patient Comments: take five (5) tablet (s) by mouth daily. Record review of a hospital discharge document for Resident #1 titled, Home Medication List, dated 10/16/2025, revealed, Continue Medications. These are your current medications to keep taking at home. Further record review revealed, Carbidopa-levodopa 25-100mg tablet. Five tab oral daily. Record review of a facility document titled Drug Regimen Review, revealed Resident #1's name and revealed the regimen review was completed for Resident #1's admission to the facility and the physician or NP were notified of the review on 10/16/2025 at 6:18 p.m. Record review of Resident#1's October 2025 MAR revealed an order, Carbidopa-Levodopa oral tablet 25-100mg (Carbidopa-Levodopa) Give 5 tablets by mouth one time a day for Parkinson's. The start date was 10/17/2025 at 9:00 a.m. and discharge date was 10/20/2025 at 11:11 a.m. The MAR was initialed, indicating the Carbidopa-Levodopa was administered, on 10/17/2025, 10/18/2025, 10/19/2025 and 10/20/2025. An order revealed, Carbidopa Oral tablet 25mg (Carbidopa), Give 1 tablet by mouth two times a day for Parkinsons. One tab at [3 p.m.] & [7:00 p.m.]. The start date was 10/21/2025 at 7:00 p.m. and discharge date was 10/22/2025 at 12:16 p.m. The order was initialed, indicating it was administered, on 10/21/2025 at 4:00 p.m. An order revealed, Carbidopa-Levodopa oral tablet 25-100 mg (Carbidopa-Levodopa) give 1.5 tablet by mouth two times a day for Parkinson's. 1 1/2 tabs at 8:00 a.m. and 11:00 a.m. The start date was 10/21/2025 at 11 a.m. and discharge date was 10/22/2025 at 12:16 p.m. The order was initialed indicating it was administered on 10/21/2025 at 11:00 a.m. Record review of a facility document titled, SNF/NF to Hospital Transfer Form revealed Resident #1 was transferred to the hospital for a med error at 10/21/2025 at 5 p.m. and the document was completed by the ADON. Record review of Resident #1's progress notes, dated 10/21/2025 at 5:31 p.m., by LVN C, revealed, Patient was returning to her room after dinner and this nurse (LVN C) and staff noticed patient had altered mental status and shortness of breath. Patient was 676274 Page 3 of 10 676274 10/24/2025 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0755 Level of Harm - Actual harm Residents Affected - Few unable to hold herself up in her wheelchair. This nurse took patient to her room, administered O2 @ 2L, via nasal canula, this nurse completed a head-to-toe assessment, and this nurse immediately called [ADON]. A progress note dated 10/21/2025 at 5:45 p.m. by the ADON revealed, LATE ENTRY. Resident sent out to [hospital] via stretcher escorted by EMS per [physician] for further evaluation and treatment d/t AMS and changes in vitals. Administrator and DON informed on [sic]incident. Record review of a pharmacy medication packing list, dated 10/20/2025, revealed Resident #1's Carbidopa-Levodopa 25-100mg give 1 tablet at 3 p.m. and 7 p.m. arrived at the facility on 10/20/2025. Record review of a pharmacy blister pack, revealed Resident #1's Carbidopa-Levodopa 25-100mg give 5 tablets daily had 5 tablets in each blister pack and 4 blisters were opened and contained no tablets. Record review of a pharmacy blister pack for Resident #1's Carbidopa 25mg give 1.5 tablet at 8:00 a.m. and 11:00 a.m. had 28 blisters and no blister packs were open, indicating no medication was administered from the blister card. Record review of a pharmacy blister pack for Resident #1's Carbidopa-Levodopa 25-100mg give 1 tablet at 3:00 p.m. and 7:00 p.m. had 28 blisters and no blister packs were open, indicating no medication was administered from the blister card. During an observation 10/23/2025 at 12:00 p.m., MA A was observed administering two medications to Resident #2. The medications were Baclofen 5 mg scheduled for 12:00 p.m. and Pregabalin 150mg scheduled for 1:00 p.m. MA A was observed comparing the blister pack to the MAR prior to administration to verify medication accuracy. The medication blister pack and the physician order in Resident #2's MAR was observed and the orders matched. Resident #2 was administered the medications and swallowed the medications without complications. During an observation 10/23/2025 at 3:51 p.m., LVN B was observed administering one medication to Resident #3. The medication was Eliquis 5mg scheduled for 3:00 p.m. LVN B was observed comparing the blister pack to the MAR prior to administration to verify medication accuracy. The medication blister pack and the physician order in Resident #3's MAR was observed and the orders matched. Resident #3 was administered the medications and swallowed the medications without complications. During an observation 10/23/2025 at 3:55 p.m., LVN B was observed administering one medication to Resident #4. The medication was Eliquis 5mg scheduled for 4:00 p.m. LVN B was observed comparing the blister pack to the MAR prior to administration to verify medication accuracy. The medication blister pack and the physician order in Resident #4's MAR was observed and the orders matched. Resident #4 was administered the medications and swallowed the medications without complications. During an observation 10/23/2025 at 4:40 p.m., Resident #1, was observed lying in a hospital bed asleep with an IV in the left forearm. Resident #1 presented comfortable and did not display any signs of distress. Resident #1 did not wake up or arouse to verbal stimuli and was not able to be interviewed. During an interview on 10/23/2025 at 12:08 p.m., MA A, stated she administered medications to Resident #1 on 10/18/2025 and 10/19/2025. MA A stated Resident #1 had an order for Carbidopa-Levodopa and the administration instructions were to administer 5 tablets once a day. MA A stated she administered the medication to Resident #1 around 9:00 a.m. on 10/18/2025 and 10/19/2025. During an interview 10/23/2025 at 4:35 p.m., the Hospital RN, stated Resident #1 was admitted to the hospital with a diagnosis of an overdose of the medication Carbidopa. Hospital RN stated Resident #1 was very drowsy and received a nutritional supplement by IV for nutrition. The Hospital RN stated there was not a discharge plan at that time. During an interview with LVN C, 10/24/2025 at 9:24 a.m., LVN C stated Resident #1 admitted to the facility from the hospital around 5:00 p.m. on 10/16/2026. LVN C stated Resident #1 admitted with discharge orders from the hospital and LVN C texted the hospital orders to the (NP) G, who approved the orders, and the orders were entered into the EMR for administration. LVN C stated Resident #1 was admitted to the facility with a bottle of Carbidopa-Levodopa that contained tablets and was the supply 676274 Page 4 of 10 676274 10/24/2025 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0755 Level of Harm - Actual harm Residents Affected - Few Resident #1 used at home. LVN C stated she administered Resident #1's 5 tablets from that bottle on the morning of 10/17/2025 and Resident #1's blister pack from the pharmacy arrived at the facility later on 10/17/2025. LVN C stated she administered Carbidopa-Levodopa to Resident #1 on 10/20/2025 from the pharmacy blister pack. LVN C stated NP G approached her with Resident #1's RP on 10/20/2025 and NP G stated she was going to change Resident #1's administration times for the Carbidopa-levodopa and discontinue the order for the five tablets to be administered at one time, once a day. LVN C stated NP G gave the order to administer 1.5 tablets at 8 a.m. and 11 a.m. daily and one tablet at two separate times in the afternoon. LVN C stated NP G said to start the new administration of the Carbidopa-levodopa on 10/21/2025. LVN C stated she entered the new orders into Resident #1's EMR to start on 10/21/2025 at 11 a.m. and LVN C sent the order to the pharmacy to get new blister packs. LVN C stated the blister pack on the medication cart contained five pills per blister for the daily administration and the new blister packs would have 1 or 1.5 tablets per blister. LVN C stated she placed a sticker on the old administration blister pack that read, change in direction and indicated that the order for the medication changed. LVN C stated when a medication aide or nurse observed a change in direction sticker on a blister pack, that person should review the MAR, change in the order, and administer the medication according to the administration record. LVN C reviewed Resident #1's MAR and stated she entered a new Carbidopa-levodopa order for one tablet at 3 p.m. and 7 p.m. with a start date of 10/21/2025. LVN C stated she was not sure why the time for administration on the MAR was 3:00 p.m. and 4:00 p.m. LVN C stated MA D notified LVN C the Carbidopa-Levodopa showed up on her MAR for administration at 4 p.m. so MA D gave Resident #1 one tablet of Carbidopa-levodopa from Resident #1's personal medication bottle that was on the medication cart. LVN C stated MA D showed LVN C the blister pack that had five pills to be administered and told LVN C the blister pack did not match the order to administer one tablet and the order was to administer at 7 p.m. but appeared in her EMR for administration at 4 p.m. LVN C stated when MA D administered one tablet of the medication around 4 p.m., MA D noted a change in condition of Resident #1. LVN C stated she called MA F who administered medications to Resident #1 on the morning of 10/21/2025 and MA F stated she gave Resident #1 five tablets of the Carbidopa-Levodopa at 8 a.m. and 11 a.m. on the morning of 10/21/2025 and used the blister pack with the 5 tablets per administration that had a change of direction sticker on it indicating the order had changed. LVN G stated she went to assess Resident #1 and Resident #1 was observed to be lethargic and not responding when spoken to. LVN C stated she notified the ADON of Resident #1's change in condition and that MA F stated she administered a total of 10 tablets of Carbidopa-levodopa to Resident #1 that morning (10/21/2025). LVN C stated the physician was notified and Resident #1 was transferred to the hospital for evaluation. During an interview on 10/24/2025 at 9:29 a.m., MA D stated Resident #1 had a blister pack on the medication cart with 5 tablets in it to be administered at once and MA D observed that Resident #1's order was to administer 1 tablet, so MA D got 1 tablet out of Resident #1's personal medication bottle on the medication cart. MA D stated she then notified LVN C the medication administration orders did not match the blister pack, and the order was scheduled for 7 p.m. but showed up on the MAR for administration at 4 p.m. MA D stated LVN C called MA F while MA D was at the nurses station and LVN C asked MA F what Resident #1 was administered that morning. MA D stated LVN C stated, Are you sure you gave her two doses of the 5 pills at 8 a.m. and 11 a.m.? MA D stated LVN C hung up the telephone and told the ADON the same information. MA D stated when she administered Resident #1's medication around 4 p.m., Resident #1 was awake and appeared confused but did not appear different from her baseline. MA D said between 4:30 p.m. and 5:00 p.m., Resident #1 was observed not responding to staff and was assessed by the nurses. MA D stated 676274 Page 5 of 10 676274 10/24/2025 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0755 Level of Harm - Actual harm Residents Affected - Few the correct blister packs with the correct dosage had arrived from the pharmacy and were on the cart, just not in the right place when she administered the 1 tablet at 4 p.m. on 10/21/2025. During an interview on 10/24/2025 at 9:31 a.m., RN E, stated LVN C completed Resident #1's medication regimen review with the physician on the day of Resident #1's admission. RN E stated she worked the night shift and reviewed the orders. RN E stated she read the order for the Carbidopa-levodopa 5 tablets daily and called the hospital to question the accuracy of the order. RN E stated she spoke to a nurse at the hospital on [DATE] about the medication dosage .and the person she spoke to said that was how the medication was administered at the hospital. RN E stated she called the on-call physician number and spoke to a Nurse Practitioner. RN E states she told the NP the medication was usually administered at separate times throughout the day but Resident #1's order was for all five tablets to be administered at one time. RN E stated she told the on-call NP that she verified with the hospital that was how the medication was being administered. RN E stated the on-call NP did not change the order and stated she would let the facility physician or NP know so they could review it on the next visit.During an interview on 10/24/2025 at 11:32 a.m., MA F stated she was assigned to administer medications to Resident #1 on 10/21/2025. MA F stated she administered the Carbidopa-Levodopa around 12:00 p.m. to Resident #1 and stated, I pulled the blister pack and did what the blister pack told me. MA F stated she did not see a change in direction sticker and followed the instructions on the blister pack. MA F denied giving the medication at 8 a.m. and stated the medication only appeared on her MAR for administration around 11:00 a.m. MA F stated she felt the nurse should have informed her there was a change in the administration order. MA F stated she looked at the order on the MAR as well and stated for proper medication administration, a person has to compare the order on the MAR to the blister pack and notify the nurse if there was a discrepancy in the orders. MA F stated she did not recall the order on the MAR being different than the order on the blister pack. MA F stated LVN G called her on 10/21/2025 around 4:30 pm. and asked MA F what she administered to Resident #1 that morning and MA F said she told LVN G that she administered 5 tablets of the Carbidopa-Levodopa around noon. During an interview on 10/24/2025 at 12:30 p.m., MA A stated she administered Resident #1's Carbidopa-Levodopa from Resident #1's blister pack on 10/18/2025 and 10/19/2025. During an interview on 10/24/2025 at 12:54 p.m., NP G stated she was notified of Resident #1's hospital discharge orders and gave the order to resume the medications prescribed from the hospital. NP G stated she met with Resident #1's RP on 10/20/2025 at the facility and reviewed the medications. NP G stated the responsible party explained how Resident #1 was administered the Carbidopa-Levodopa at home and stated, it was odd to me that she was getting 5 at once but her bottle from home said 5 tabs a day as well. NP G stated she talked to LVN C and changed the order to reflect new administration times throughout the day so Resident #1 was not taking the 5 tablets at once. NP G stated 5 tablets a day was not an unusual dose and other people were prescribed the same dosage or more of the pills a day, but the administration was usually throughout the day. NP G stated a person taking 5 tablets of Carbidopa-Levodopa at once would likely not cause any side effects or harm but taking more than that dosage, like a double dose, could cause lethargy (tiredness). NP G stated, if she only received 5 tablets, I do not think that would have had any effect. If she got a double dose of the medication that morning, on 10/21/2025, that could have made her drowsy or incoherent. NP G stated it was important to administer medication as ordered because, you don't want to over or under medicate a patient with a wrong dosage.During an interview on 10/24/2025 at 1:20 p.m. Resident #1's RP stated Resident #1 was taking 5 tablets of Carbidopa-Levodopa at home at scheduled times but stated the bottle from home stated take 5 tablets daily. The responsible party stated the hospital was administering it at scheduled times, 676274 Page 6 of 10 676274 10/24/2025 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0755 Level of Harm - Actual harm Residents Affected - Few but the discharging doctor wrote 5 pills daily without specifying if the tablets should have been administered at separate times throughout the day. The responsible party stated they understood why the facility was following the order as the hospital wrote the order upon discharge from the hospital. The responsible party stated they met with the Nurse Practitioner on 10/20/2025 and explained to her how the medication should be administered throughout the day and said, we got it all straightened out that day. The responsible party stated they were notified on 10/22/2025 by a nurse at the facility that Resident #1 was administered 5 tablets at once on 10/21/2025, had a change in condition, and was transferred to the hospital.During an interview on 10/24/2025 at 2:07 p.m., the ADON stated Resident #1's medications, including the five tablets a day of Carbidopa-Levodopa were reviewed upon admission by the NP and the ADON. The ADON stated, It did seem odd when you look back at it, where was everyone's critical thinking. The ADON stated he became aware of a concern with Resident #1's Carbidopa-Levodopa order when LVN C notified the ADON on the afternoon of 10/21/2025 that Resident #1 had a change in condition and seemed different. The ADON stated LVN C also told the ADON that MA D had reported to LVN C that something was wrong with the administration order of the Carbidopa-Levodopa and it was firing off at 4:00 p.m. instead of 7:00 p.m. and the ADON stated he looked at the blister pack and it was the original blister pack with 5 tablets and it had a change in direction sticker on it. The ADON stated MA D did not give the 5 tablets from the blister pack and followed the order to give one tablet. The ADON stated MA D pulled from the resident's home supply bottle. The ADON stated he instructed LVN C to call MA F and ask what MA F administered and the ADON observed LVN C nodding her head acknowledging that [MA F] gave her 10 pills and that is what I understood but it turns out that she gave her 5 pills instead. The ADON stated he counted the administration doses and determined on 10/21/2025, MA F Resident #1 3.5 tablets over the newly ordered dose amount. The ADON stated the new blister packs were on the medication cart at the time of MA F's medication administration and stated MA F grabbed the wrong blister pack and did not look at the change in direction sticker and did not verify the blister pack instructions matched the MAR. The ADON stated the discontinued blister pack should have been removed at the time the order was changed to avoid any medication errors. The ADON stated when he was notified Resident #1 had a change in condition, he assessed her around 5:00 p.m. on 10/21/2025 and observed her to appear weak and lethargic with altered mental status (confusion). The ADON stated Resident #1 was taken to her room, placed on oxygen, the physician was notified, and Resident #1 was transferred to the hospital for evaluation. The ADON stated it was important to administer medications accurately because, you do not want to give the wrong medication. During an interview on 10/24/2025 at 4:23 p.m., the DON stated when administering a medication, the person administering the medication should follow the five rights of medication pass which included ensuring it was the right patient, correct dosage, correct route for administration and the person should validate the medication blister pack matched the order on the MAR. The DON stated change of direction stickers were used to identify a change in an order and a person administering medication should verify the new order on the MAR was used by checking the order in the EMR. The DON stated he was notified of the medication error for Resident #1 by the ADON on 10/22/2025 and stated they completed a QAPI action plan, initiated in-services with direct care staff and stated there were 34 nurses and medication aides. The DON stated a pharmacy representative completed a cart audit on 10/22/2025 and compared resident orders in EMR to the resident blister packs to ensure accuracy. The DON stated MA F was suspended on 10/22/2025 and terminated on 10/23/2025. The DON stated the Medical Director, who was Resident #1's physician, was notified of the medication error on 10/21/2025. The DON stated residents who received medications from MA F on 10/21/2025 were assessed to ensure there were no 676274 Page 7 of 10 676274 10/24/2025 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0755 Level of Harm - Actual harm Residents Affected - Few additional concerns and none were identified.During an interview on 10/24/2025 at 5:52 p.m., the Administrator stated he was notified of the medication error and hospitalization of Resident #1 on 10/21/2025. The Administrator stated they immediately set up a QAPI plan to ensure residents were free from medication errors. The Administrator stated MA F was suspended pending the investigation into the error and the ADON completed a medication error report and started in-servicing on medication administration safety to include change in direction stickers and abuse and neglect. The Administrator stated they conducted a record review to determine how the medication error occurred and stated their audit revealed the medication was administered from the blister pack on 10/18/2025, 10/19/2025, 10/20/2025 and erroneously on 10/21/2025. The Administrator stated the audit revealed that Resident #1 was given 3.5 tablets of Carbidopa-Levodopa more than should have been administered on the morning of 10/21/2025. The Administrator stated a pharmacy technician completed an audit on all of the blister packs and MARs on 10/22/2025. The Administrator stated the Medical Director and the Ombudsman were notified of the medication error. The Administrator stated 2 additional residents were prescribed Carbidopa Levodopa, Resident #5, and Resident #6. The Administrator stated all levels of things from mild effects to death of a resident could occur when a resident was administered the incorrect medication or dosage. The facility course of action prior to surveyor entrance included:Record review of a facility document provided by the Administrator titled, QAPI Action Plan, revealed, Problem: Medication error by CMA which required a resident to be sent out to local ER for further evaluation and treatment and Goal: To ensure all residents' health and safety by receiving proper care i.e. free from medication errors. The actions included: called 911. Inservice on medication safety and abuse/neglect/exploitation prevention. Suspend CMA for medication error 10/21/2025. Charge nurses to monitor all resident who were in the care of this CMA for change in condition related to medication errors. Notify physician. Notify responsible party in person at the facility. In-service nursing staff on making proper notifications to family members/responsible party. Run medication report for all residents who are on Carbidopa-Levodopa. Document in the clinical record of all residents in the care of this CMA to monitor for s/s of change in condition related to possible medication errors. Nursing administration to verify physician orders related to medications. Resident affected by this incident was sent to hospital per physician order. The document revealed, further investigation revealed: 1. What was the medication error? 10/21/2025 5 tablets administered at 11 a.m. of Carbidopa-Levodopa 25-100mg. 2. What medication? Carbidopa-Levodopa 25-100mg. 3. What was the orders? A. Carbidopa-Levodopa 25-100mg 5 tabs once a day on admission date 10/16/2025. B. Then the order changed on 10/20/2025 to Carbidopa-Levodopa 25-100mg give 1.5 tabs po at [8:00 a.m.] and [11:00 a.m.]. Carbidopa-Levodopa give 1 tab po at [3:00 p.m.] and [7:00 p.m.]. Start date of new order was 10/21/2025. 4. What was the frequency the medication was given? Original order 5 tablets once a day, then 5 tablets in total per day 3 in the morning and 2 at night. 5. What was the number of dosages the medication error occurred? One 10/21/2025 at 11:00 a.m. 6. How many pills did she take over the physician ordered amount? 3.5 tablets.Record review of a facility document titled Medication Error Report, revealed the person completing the report was the ADON on 10/21/2025 and the resident listed was Resident #1. The report listed the medication as Carbidopa-Levodopa 25-100mg and frequency ordered was 1.5 tabs at 8 a.m., 1.5 tabs at 11 a.m., 1 tab at 3:00 p.m. and 1 tab at 7 p.m. Description of the medication error was checked wrong dose. Description of the incident revealed, [MA F] was assigned at 10/21/2025 to Recovery (name of hallway) to administer medications. At 4:30 p.m. [MA D] was to give Resident #1 medication, noticed her condition was different, charge nurse called ADON. Medication Carbidopa-Levodopa was noticed to be wrong at 4:30 p.m. [LVN C] called [MA F] and she admitted to giving 5 pills in the 676274 Page 8 of 10 676274 10/24/2025 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0755 Level of Harm - Actual harm Residents Affected - Few morning, read order incorrectly. [ADON] informed. Date and time error occurred was 11:00 a.m. and date and time error discovered was 4:30 p.m. Immediate action taken revealed, Resident has change in vitals, lethargic, pupils dilated to 6, unable to respond to commands. VS 140/78, 74, RR 14, T 97.8, O2 90% RA, weakness, unable to speak or voice needs. The document revealed the physician was notified at 5:45 p.m. and the family/responsible party were notified at 6:00 p.m. Corrective action taken revealed, administered O2/2L via NC, called 911 immediately, informed [physician] of incident and emergency medical attention. Contributing factors revealed, failure to use 5 rights of proper medication administration. Preventive/Corrective Actions revealed, policy/procedure reviewed, staff counseling or retraining and follow up audits scheduled. Describe planned prevention measures revealed, [MA F called by Staffing Coordinator and informed her of being placed on suspension pending investigation and to immediate termination. Staff will be in-serviced on proper medication administration. Record review of a facility document titled Disciplinary Action Form revealed MA F listed as the employee and date of hire was 01/18/2025. The offenses checked were employee conduct, safety, company philosophy and failure to complete duties as assigned. The new violation information revealed, This letter serves as formal notice of termination of your employment, effective immediately, with [facility], due to a serious medication administration error that resulted in a change in condition for [Resident #1] and Due to the severity of the violation, the company decided to forego the normal disciplinary process and moved to immediate termination. The document, dated 10/22/2025, was signed by MA F and the ADON. Record review of an undated facility staff roster revealed 34 licensed nursing and medication aides. Record review of a facility in-service training, dated 10/22/2025, and titled, Medication Safety & Abuse/Neglect/Exploitation Prevention revealed training included the definition of a medication error, examples of medication errors including giving the wrong dose, clarifying unclear orders, reading labels carefully, and using safety checks like MAR vs. medication label vs. physician order. The in-service included immediate steps to take when a medication error occurs that included assessing and monitoring the patient for adverse effects, notification of the DON, physician, and responsible party. The in-service was signed by 33 direct care staff members and 5 were documented as notified over the phone. Record review of an email from the Administrator to the Ombudsman, dated 10/23/2025 at 11:04 a.m., revealed the Ombudsman was notified of the medication error.Record review of an email dated 10/22/2025 at 4:27 p.m. from the Administrator to HHSC Complaint and Incident Intake revealed the Administrator reported the medication error and hospitalization of Resident #1 to HHSC. Record review of an undated Resident Room Roster, provided 10/24/2025 revealed 18 residents resided on the Recovery hallway.Record review of 10 resident's (Resident #2,7,8,9,10,11,12,13,14,15) revealed a progress note on 10/21/2025 that read, Resident has no s/s or changes with administration of medications.Record review of Resident #5's October medication administration record revealed an order, Carbidopa-Levodopa 25-100mg give 1 tablet by mouth three times a day for Parkinson's Disease The medication was scheduled for 8 a.m., 1 p.m. and 5 p.m. and there were no holes in the MAR.Record review of Resident #6's October medication administration record revealed an order, Carbidopa-Levodopa 25-250 mg. Give 1 tablet by mouth four times a day related to Parkinsonism and was scheduled for 6 a.m., 12 p.m., 6 p.m. and 9 p.m. There were no holes in the MAR. During an interview with MA F, 10/24/2025 at 11:32 a.m., MA F stated she was terminated from her job as a medication aide due to a medication error. During interviews with 1 MA (weekends), 4 LVNs (day shift), 1 RN (night shift) 1 MA (afternoon shift) and 1 MA (day shift and received training by phone) the staff members stated they received training on medication administration including safe administration and using 5 rights of medication administration, change of direction stickers, validating blister pack orders match the 676274 Page 9 of 10 676274 10/24/2025 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0755 Level of Harm - Actual harm Residents Affected - Few physician orders, notifying the physician and charge nurse if orders do not match prior to administration. The staff members received training on abuse and neglect and were able to identify when and who to report allegations of abuse or neglect. During an interview with Resident #5, 10/24/2025 at 5:43 p.m., Resident #5 stated she received her Carbidopa-Levodopa three times a day and stated she had been receiving her medication accurately and on time and expressed no concerns with medication administration. During an interview with Resident #6, 10/24/2025 at 5:48 pm, Resident #6 stated he received his Carbidopa-Levodopa four times a day and expressed no concerns with medication administration. During an observation with LVN J, 10/24/2025 at 5:39 p.m., LVN J pulled Resident #5 and #6 Carbidopa-Levodopa 25-100 mg blister pack from the medication administration cart and Resident 5 and Resident #6's blister pack matched the resident's Carbidopa-Levodopa MAR. 676274 Page 10 of 10