Inspection·January 20, 2026

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #1's nurses notes documented the following:1/15/26 at 8:39 a.m. - Resident #1 was transferred to a hospital related to medication error - NP ordered for resident to be transferred out for close evaluation. This is intended to serve as notice of an emergency transfer.1/16/26 at 4:14 p.m. - Resident #1 readmitted /returned from the hospital. Reason for hospital visit: insulin overdose During an interview on 1/20/26 at 9:55 a.m., the Administrator stated LVN A gave Resident #1 her own insulin, but it was the fast-acting insulin, not the long-acting insulin that was ordered for that time of day. During an interview on 1/20/26 at 10:25 a.m., the DON stated on 1/15/26, she was in her office getting ready for a morning meeting when LVN A came to her and said she had given the wrong insulin to Resident #1. The DON stated LVN A meant to give Lantus - a long-acting insulin but gave the short-acting insulin by mistake. The DON stated LVN A realized after about 10 minutes that she had given the wrong insulin to Resident #1 and came directly to her office. The DON stated she immediately went to assess Resident #1 and called the NP to see what she needed to do to get Resident #1 situated. The DON stated the NP said to start an IV for D5, if needed, then the NP called another NP and then the MD and the MD informed her to send the resident to the hospital. The DON stated that very day, they educated LVN A and suspended her, she was still suspended. The DON stated the NP also educated LVN A about searching for medications on Google. The DON stated there were always extra mediations in the Emergency kit if needed. The DON stated LVN A was a new nurse and had been a nurse since [NAME] 2025, when she graduated LVN. The DON stated all the nurses talked very highly of LVN A, but she made a very bad mistake. The DON stated LVN A was still suspended for the time being. During an interview on 1/20/26 at 12:46 p.m., LVN A stated she had gone to her medication cart and had already taken Resident #1's vitals but she always wanted her insulin at a certain time. LVN A stated she was looking for Resident #1's insulin pens as she had two the last time she took care of her, but there was only one pen in the medication cart. LVN A stated afterwards, she had found a vial of Resident #1's insulin but not the pen and it was the long-acting insulin she needed. LVN A stated she contacted ChatGPT, which is like an AI thing the younger generation uses instead of Google, and it said the insulin was the right kind, but she admitted to not reading all of the answer. LVN A asked the State surveyor if she knew what AI was because all the younger generation used it, to which the State surveyor informed LVN A that she was aware of AI. LVN A stated she had gone on to give insulin to another resident, and that resident's insulin was the same as Resident #1's and that was when she knew she had given the wrong medication (short-acting insulin) to Resident #1. LVN A stated she immediately locked her medication cart and went to the Administrator's office and then the DON and told them what happened. LVN A stated Resident #1 was doing good and they gave her two glasses of apple juice and some crackers, and Resident #1 drank both glasses of apple juice and some of the crackers. LVN A stated she checked Resident #1's blood sugar and it was 200 and she checked Resident #1's blood sugar 10 minutes later and her blood sugar was 145. LVN A stated right after that, Resident #1 was sent to the hospital for observation and the resident was not in any distress. LVN A stated the NP wanted her sent to the hospital for further evaluation and treatment. LVN A stated she was terrified by the mistake she made. LVN A stated she would never do that again and instead of contacting ChatGPT, she would go ask the charge nurse or the DON for assistance when she was not sure of the medication she was giving. During an interview on 1/20/26 at 1:54 p.m., Resident #1 stated she remembered getting an IV when she got to the hospital. Resident #1 stated the first thing they did after she got the wrong insulin was give her a glass or two of apple juice and some crackers. Resident #1 wasn't upset about getting the wrong insulin until she found out how serious it could be. Resident #1 stated she usually got insulin from a pen, but she had gotten insulin from a regular insulin syringe. Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 2 of 3 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 676341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated she remembered the nurse (LVN A) was scared to death. Resident #1 stated the doctor insisted on sending her to the hospital so she could be monitored closely, and she was just monitored at the hospital and then she was sent back to the facility. Resident #1 stated she did not have any low blood sugars at the hospital. Resident #1 stated those young nurses that were coming to the facility or PRN nurses, she did not understand why the facility used so many of them. Resident #1 stated she was uncomfortable with new nurses, and she trusted the older nurses that had been in the facility for a while. Resident #1 stated she was glad that someone was doing a follow-up on giving her the wrong insulin because that should never have happened. (Resident #1's blood sugars were checked with the medical record on 1/15/26 before being transported to the hospital and all of her blood sugar were in a normal range for her.) During an interview on 1/10/26 at 2:11 p.m., Resident #1's NP stated she was told that the nurse was out of long-acting insulin and googled to see if the other insulin was the same thing and google said it was, so she gave 45 units of short acting insulin in error. The NP stated she was very upset when she was told that because it was a very serious situation. The NP stated she called the doctor and informed him of what happened, and he said to send her to the hospital because they could monitor her better. The NP stated the facility had everything in house to take care of her, but she needed closer monitoring and the resident would be better off in the hospital. The NP stated she was aware that the nurse who made the error was a new nurse and new to the facility but nursing 101 would tell you to look for the DON for any answers that would be needed. The NP state a nurse should never google to make a nursing judgement, a nurse should always ask the DON or ADON, that was what they were there for. The NP stated Luckily, Resident #1 was fine and thought her blood sugar never got below 120. Record review of the facility's, Medication Administration and General Guidelines, undated, documented the following:Policy: Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in LinkRX otherwise authorized personnel should refer to Drug Reference material provided by facility. -Subcutaneous Injection Administration:-Insulin Injection:1. Assure type of insulin, unit dosage and syringe are correct.-Procedure:2. Read label three times before administering, check with MAR.4. Check label with order. Record review of the facility in-service training, dated 1/15/26, titled Medication Rights, documented the following:-There are 5 rights to medication administration *Right Patient *Right Medication *Right Dose *Right Route *Right Time*Always check you five rights before giving any medication to a resident. It is our responsibility to ensure that safe practice is always followed.*If a medication error occurs, report it immediately to the DON/ADON. While not all medication errors can cause harm, all must be taken seriously and reported.*If you have a question about an order or medication, please get in touch with the DON/ADON or even another seasoned nurse to ensure we are practicing safe practices.*Best practices include: *Clarifying unclear orders *Know what you are administering *Verify allergies *Verifying the 5 rights to medication administration.*If it feels unsafe, stop and clarify. If medication is not available, get with the DON/ADON who can get into contact with the MD/NP and get clarification and new orders. Event ID: Facility ID: 676341 If continuation sheet Page 3 of 3