Health inspection·July 2, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mmHg-06/28/25 at 11:15 a.m. 97/68 mmHgThere were no other levels documented between 06/27/25 at 3:16 p.m. through 06/28/25 at 11:15 a.m. Review of MT E's Statement, dated 06/28/25, reflected. On 06/27/25, my shift started at 2:00 p.m.-10:00 p.m [Resident #1] had been admitted on day shift. At the end of my shift, [Resident #1's] medications had not been delivered. My Nurse [LVN B] said to leave her medications open and she would give [Resident #1's] medications. The only medication from form the emergency medication kit was Gabapentin on my shift. Review of LVN B's Statement, dated 06/28/25, reflected, [Resident #1] was new admission on [DATE]. Medications were ordered from Pharmacy by 6:00 a.m.-2:00 p.m. nurse. Medications had not yet arrived from Pharmacy by the end of my shift at 10:00 p.m. Informed 10:00 p.m.-6:00 a.m. nurse of this, she said she would give medication when they arrived. Review of LVN D's Statement, dated 06/27/25, reflected, Shift 10 p.m.-6:00 a.m.: At this time, [Pharmacy] delivers medication for new patient admission, but does not deliver 2 medication that were on patient's medication list. Those medication were Midodrine. Nurse from previous shift informed to be on lookout for new patient's mediation. Once medication arrived, I asked delivery driver from pharmacy if he was missing a bag due to medication not being in stock with others. Driver states that was what she had and all they sent. This was communicated to morning nurse to be on the lookout for these medication from morning run. Issue was not pressed on my shift due to patient's VS WNL and denial of patient. Review of Resident #1's Progress Notes reflected:-LVN A's note on 06/28/25 at 10:02 a.m., This nurse was made aware at 8:10 a.m. of missing mediation by medication aide. Medication is Midodrine 10mg PO TID. Medication not available in [Emergency Medication Kit]. This nurse faxed resident's medication list to [Pharmacy] before 2:00 p.m. on 06/27/25. Resident's medications placed in [Electronic Health Record] before 2:00 p.m. on 06/27/25. All resident's medication except Midodrine delivered to facility on 06/27/25. Resident assessed. Resident's BP was 86/60. Resident denied pain. Resident denied lightheadedness or dizziness. Neuros WNL. No seizure activity noted or reported. Resident stable at this time. Nursing staff checking on resident every hour. This nurse called [Pharmacy] with no response. This nurse called [Another Pharmacy] and was told by Pharmacist that [Pharmacy] did not have order for Midodrine. This nurse called prescription into pharmacy. This nurse asked Pharmacist for STAT local delivery. Pharmacist told this nurse medication could be at facility between 12:00 p.m. and 4:00 p.m. depending on local pharmacy. Geriatric on-call FNP aware and ordered STAT Midodrine prescription from Pharmacy. RP aware and told this nurse that it was unacceptable that resident did not receive medication. Family member will pick up medication and deliver to facility for administration. DON aware. Admin aware. Resident resting in bed with call light within reach. Will continue to monitor. VS 88/64.-LVN A's note on 06/28/25 at 11:20 a.m., Medication brought to facility via family friend at 10:30 a.m. Resident received dose. BP at 10:15 a.m. was 92/58. BP at 11:15 a.m. was 97/68. No c/o pain. No s/s of distress noted. Neuros WNL. No lightheadedness/dizziness noted or reported. No seizure activity noted or reported. DON aware. Admin aware. RP aware. Family at bedside. Resident resting in bed with call light within reach. Will continue to monitor. There were no other previous notes. Review of the facility's Grievances, from April through July 2025, reflected Resident #1's RP filed a grievance about Resident #1's medication availability on 06/28/25. The DON and ADM were assigned to investigate the grievance on 06/28/25. [JM8] [JK9] Review of the facility's Incident Log, from April through July 2025, reflected Resident #1 had a wrong time medication error incident documented on 06/28/25 at 8:10 a.m. Review of the facility's Pharmacy Information, undated, reflected, Pharmacy Order Timelines: New Orders and New Admissions: Monday-Friday: Ordered by 11:30 a.m. and delivery window was 1:30 p.m.-6:00 p.m. and ordered by 6:00 p.m. and delivery window was 8:00 p.m.-12:00 a.m.Emergency Medication Procedure: If medication is needed prior to your next (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676364 If continuation sheet Page 2 of 5 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 676364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morada Temple 4312 S 31st St Temple, TX 76502 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 - Few scheduled delivery, please follow your regular process to submit the order, then call to request the medications STAT.Checking Order Status: 1. Check [Pharmacy] - The Rx Order Status will show the results of the last 72 hours of orders.During an interview on 07/02/25 at 10:20 a.m., the ADM stated she was still investigating Resident #1's self-reported incident. During an interview on 07/02/25 at 1:06 p.m., Resident #1 stated she was admitted to the facility last Friday (06/27/25) in the afternoon. Resident #1 stated she did not receive her blood pressure medication (Midodrine) that was to help bring her blood pressure up whenever it got low. Resident #1 stated her blood pressure medication was the only medication she did not receive when she was admitted to the facility. Resident #1 stated her family asked her on 06/27/25 if she received her blood pressure medication and she told her family that she did not receive it. Resident #1 stated she felt dizzy and lightheaded during the time she did not receive her blood pressure medication which made it hard for her to sleep. Resident #1 stated she reported to the staff that she was feeling dizzy and lightheaded. Resident #1 stated the staff did not say or provide her with anything after she reported to them feeling dizzy and lightheaded. Resident #1 stated the staff checked her vitals three times a day. Resident #1 stated staff told her that her medication was already with the pharmacy and that they were waiting for her medication from the pharmacy whenever they checked her blood pressure during the time frame she did not have her medication. Resident #1 stated she received her blood pressure medication from her family, who picked up the medication and gave it to her on Saturday (06/28/25) morning between 10:30 a.m. and 11:00 a.m. During an interview on 07/02/25 at 2:18 p.m., LVN A stated he was the nurse who reported Resident #1's incident. LVN A stated Resident #1 was admitted to the facility on [DATE] around 2:00 p.m. LVN A stated he faxed Resident #1's medication list to the pharmacy and entered the orders into Resident #1's electronic health records. LVN A stated he returned to work on 06/27/25 around 7:15 p.m. and was notified by an MA that Resident #1's blood pressure medication (Midodrine) was not at the facility. LVN A stated he notified the Pharmacy and got no response. LVN A stated he notified the after hours Pharmacy, who told him that they did not receive the orders. LVN A stated he had the pharmacy conduct a STAT delivery for the medication, called the on-call MD, who ordered the medication to be sent to a local hospital, and had Resident #1's family pick up and drop off the medication to the facility. LVN A stated Resident #1's family delivered the medication on 06/28/25 at 10:00 a.m. LVN A stated the facility's emergency medication kit did not have blood pressure medication that Resident #1 needed. LVN A stated he kept a close eye on Resident #1 to make sure she was not having any symptoms, such as lightheadedness, confusion, dizziness, loss of consciousness, neurological effects, cardiovascular issues, and irregular pulse. LVN A stated Resident #1 had a history of low blood pressure. LVN A stated Resident #1 did not report any adverse effects from not receiving the blood pressure medication. LVN A stated he checked Resident #1's vitals every hour and documented the vital checks in her electronic health records. LVN A stated he and the CNAs monitored Resident #1. LVN A stated he knew it was important to ensure residents' medications were ordered and received before admission and said, Because for various medical reasons, residents need medications. They could be losing blood pressure, have a loss of consciousness, and potentially die as a result from not receiving their medication. LVN A stated the admission nurse was responsible for entering and sending the medication orders to the pharmacy. LVN A stated LVN B was Resident #1's admission nurse, but he was the one who received the medication orders to be entered and sent out to the pharmacy. LVN A stated the ADON and DON reviewed all new admission residents about 1-2 days after their admission to ensure medication orders were received, entered, and sent to the pharmacy. During an interview on 07/02/25 at 2:43 p.m., LVN B stated the admission nurse was responsible for entering and submitting residents' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676364 If continuation sheet Page 3 of 5 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 676364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morada Temple 4312 S 31st St Temple, TX 76502 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 - Few medication orders to the pharmacy. LVN B stated the admission nurse usually received a confirmation sheet reflecting if residents' medication orders were submitted to the pharmacy. LVN B stated she knew it was important to ensure residents' medications were ordered and received before admission and said, So staff had medication available for the resident. Facility pharmacy will deliver last run between 1:00 p.m.-10:00 p.m If medications don't show up, of course there was an issue with that. If the facility had it available in e-kit (emergency medication kit), can pull it. If not available, they need to get it quickly as they can. LVN B stated LVN A entered and sent Resident #1's medication orders to the pharmacy. LVN B stated the facility waited for Resident #1's medication to come the evening and the medications did not arrive. LVN B stated she told the night shift nurse that she was still waiting for Resident #1's medications to arrive at the facility. LVN B stated Resident #1's midodrine was used for her low blood pressure and was used to bring up low blood pressure. LVN B stated residents could be at risk of lower blood pressure if they did not receive their medication. LVN B stated she checked Resident #1's blood pressure and it was WNL (for Resident #1) during admission. LVN B stated she finished her shift on 06/27/25 at 10:00 p.m. and Resident #1's medication had still not arrived. LVN B stated Resident #1's vitals were to be checked every shift before administering medication. LVN B stated when she checked Resident #1's blood pressure, it was not low and not low enough to where she was concerned about the level. LVN B stated Resident #1 did not report any adverse effects from not receiving her blood pressure medication. LVN B stated the DON oversaw to ensure and would assist with medication orders being received, entered, and sent to the pharmacy. During an interview on 07/02/25 at 4:24 p.m., the DON stated charge nurses were responsible for entering and submitting residents' medication orders to the pharmacy. The DON stated this process was conducted anytime there was a newly admitted resident. The DON stated the admission nurse usually entered and submitted residents' medication orders. The DON stated she and the ADON reviewed new admission residents the same day or next business day after admission. The DON stated she knew it was important to ensure residents' medications were ordered and received before admission and said, Because for general health, if medications were not available, it could deteriorate their (residents') health. There was a potential for it to occur. Residents could have potential for going into hypotensive crisis (sudden drop in blood pressure). The DON stated she was notified by LVN A on Saturday (06/28/25) at 10:00 a.m. that Resident #1 did not have her medication available. The DON stated she was not notified before this date and time. The DON stated she could not recall who was Resident #1's admission nurse, but she believed it was LVN B. The DON stated she was unaware if LVN A or LVN B were responsible for entering and submitted Resident #1's medication orders because the incident was still being investigated. The DON stated the pharmacy told her that they did not electronically receive Resident #1's medication orders until 9:00 p.m. that night (06/27/25). The DON stated staff were monitoring Resident #1's blood pressure levels every hour. The DON stated LVN A took Resident #1's blood pressure every 15 minutes when it came down to 98. The DON stated Resident #1 was supposed to get a dose of her blood pressure medication at bedtime and in the morning. The DON stated staff told her that Resident #1's family was picking her Resident #1's medication and dropping it off at the facility. The DON stated she expected the nurses to observe Resident #1 for weakness, nauseam, and dizziness every 2 hours or 4 hours or more if needed if the medication was unavailable. The DON stated she also expected staff to offer fluids to increase intake, notify the on-call physician if a resident was not drinking fluids, elevate the resident's feet, and lowering the resident's head for better blood flow if the medication was unavailable. During an interview on 07/02/25 at 5:05 p.m., the ADM stated it was her understanding that the charge nurse receiving the resident entered and submitted the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676364 If continuation sheet Page 4 of 5 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 676364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morada Temple 4312 S 31st St Temple, TX 76502 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete orders. The ADM stated the DON oversaw to ensure the process occurred. The ADM stated Resident #1 was admitted to the facility on [DATE] at 2:00 p.m. The ADM stated shift change occurred during the time Resident #1 was admitted to the facility. The ADM stated LVN A received the discharge orders from the hospital and was helping the oncoming shift nurse with entering and submitted Resident #1's medication orders. The ADM stated LVN B was Resident #1's receiving nurse. The ADM stated The ADM stated LVN A notified her on Saturday (06/28/25) morning that Resident #1 had a medication that was not at the facility and he was monitoring her blood pressure until the medication arrived at the facility. The ADM stated she could not recall how often LVN A was checking Resident #1's blood pressure. The ADM stated she received an email from Resident #1's family who alleged neglect and she self-reported the incident. Review of the facility's In-Services, from May through June 2025, reflected there were no in-services given to staff related to Resident #1's incident. Review of the facility's Ordering/Reordering Medications policy, 07/01/24, reflected, Procedure: .6. The electronic transmission of telephone orders from electronic medical record systems to the pharmacy is permissible in stated where board of pharmacy approval has been granted or as allowed by law and regulation. 6.1. Authorized staff and prescribers may enter orders into an electronic medical record system that securely transmits prescribers' order electronically to the pharmacy.6.2.2 Facility staff should monitor pharmacy communications to address or correct all orders that required clarification before the next scheduled medication delivery, when possible. Review of the facility's Administering Oral Medications policy, 2001, reflected, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications.Preparation: Verify that there is a physician's medication order for this procedure. Reporting:.2. Report other information in accordance with facility policy and professional standards of practice. Event ID: Facility ID: 676364 If continuation sheet Page 5 of 5