Health inspection·July 28, 2025

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 observation, interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident representative of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 10 residents reviewed for notification of changes.The facility failed to notify Resident #1's physician when they did not administer his valproic acid, topiramate, levetiracetam, and lacosamide on 07/22/25-07/25/25 as ordered.The facility failed to notify Resident #1's physician after he had a seizure on 07/25/25.The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began. Findings included: Record Review of Resident #1's face sheet dated 07/27/25 indicated the resident was a [AGE] year-old male with an original admission date of 07/10/2025 and readmission date of 07/22/2025. The resident had diagnoses including acute respiratory failure with hypoxia (a life threatening condition where the lungs cannot adequately oxygenate the blood, resulting in low blood oxygen levels), epilepsy with status epilepticus (a serious neurological condition where seizures are prolonged or occur frequently without recovery between them, posing a risk of brain damage), stroke, and high blood pressure.Record Review of Resident #1's readmission assessment note dated 07/22/2025 indicated there was no BIMS score due to resident's inability to answer questions. Resident #1 was alert but unable to speak due to the presence of a tracheostomy tube (a curved hollow tube inserted into a surgically created opening in the neck to create and airway into the windpipe), he had an indwelling urinary catheter and was incontinent of bowel, required extensive to total assistance for ADLs, he had a feeding tube inserted into his abdomen, and had a cough and abnormal lungs sounds of rhonchi (low-pitched, continuous, and rattling sounds heard during breathing, often described as resembling snoring or gurgling. Record Review of Resident #1's care plan with initiation date 0710/2025 and revised 07/26/2025 indicated the resident had a seizure disorder and interventions included for the facility staff to: administer seizure medication as ordered by the doctor, and seizure documentation should have included location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity. Review of Resident #1's Physician Orders last updated 07/26/25 included: Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy, Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day for epilepsy, Topiramate 100 mg tablet Give one via G-tube two times a day for epilepsy, and Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy.Review of Resident #1's hospital after visit summary dated 07/23/2025 indicated the resident was to receive Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube three times a day, Levetiracetam 100 mg/ml Give 15 ml via G-tube every 12 hours, Topiramate 100 Page 1 of 15 676494 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some mg tablet Give one via G-tube two times a day, and Valproic Acid 250 mg/5 ml Give 10 ml via G-tube every 8 hours.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy was marked as unavailable for the PM dose on 07/22/2025,the AM dose on 07/23/2025 was blank and not marked as given, the PM dose for 07/23/2025, the AM dose for 07/24/2025 was marked as given, the PM dose for 07/24/2025 was marked as not given and the AM dose on 07/25/2025 was marked as given. There was no reason given for the blank and not given marks.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day. The 9:00 PM dose on 07/22/2025 was marked as unavailable, the 9:00AM on 07/23/2025 was blank and not marked as given, the 9:00 PM dose for 07/23/2025 was marked as given, the 9:00 AM dose for 07/24/2025 was marked as given, the 9:00 PM dose on 07/24/2025 was marked as not given, the 9:00 AM dose on 07/25/2025 was marked as unavailable. There was no reason given for the blank and not given marks. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Topiramate 100 mg tablet Give one via G-tube two times a day the AM dose on 07/22/2025 was not marked as given and was blank. There was no reason given for the blank space.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy was marked as unavailable for the 9:00 PM dose on 07/22/2025, the 9:00 AM dose and 3:00 PM doses on 07/23/2025 were blank and not marked as given. The 9:00 AM, 3:00 PM and 9:00 PM doses on 07/24/2025 were marked as given. The 9:00 AM, 3:00 PM and 9:00 PM doses on 07/25/2025 were marked as given. There was no reason given for the blank and not given marks. During an interview on 07/27/2025 at 8:23 AM, Resident #1's family member said she was visiting Resident #1 around 1:00 PM-1:45 PM on 07/25/2025, when he had a seizure. Resident #1's family member said she called the nurse to the room for assistance, and LVN A assessed Resident #1 and told them he would probably be a little sleepy. Resident #1's family member said LVN A told her she would call the doctor to see if he wanted to do any labs. Resident #1's family member said later in the evening of 07/25/2025 she went to check on Resident #1 and was informed by LVN B that Resident #1's seizure medications had not been administered prior to 07/25/2025. Resident #1's family member said LVN B told her his seizure medications had just arrived (07/25/2025). Resident #1's family member said she had LVN B print her Resident #1's medication administration record and his seizure medications were marked as unavailable or administered. Resident #1's family member said the nurses falsified the documentation because the seizure medications were not in the facility. Resident #1's family member said she was very concerned about her family member because he had a history of seizures, and in the past had been hospitalized due to uncontrolled seizures that would not stop. Resident #1's family member said she had contacted the DON and ADON C and explained her concerns regarding Resident #1's seizure medications. Resident #1's family member said the DON told her the pharmacy did not provide the medications because they were out. Resident #1's family member said the DON told her they had ordered the medications on 7/25/2025. During an interview on 07/27/2025 at 11:00 AM, LVN A said the process for when patients admitted /re-admitted was that they verified the orders with the doctor, and then they carried the orders out. LVN A said when they put the orders in the electronic health record the pharmacy sent the medications the same night. LVN A said she re-admitted Resident #1 on 07/22/2025, and she verified his admission orders. LVN A said she normally tried to call the pharmacy to notify them of admission, but she did not have the time to call because she had two admissions back-to-back. LVN A said she was off the 2 days following Resident #1's admission (did not work on 07/23/2025 and 07/24/2025). LVN A said when she returned to work on 07/25/2025, the night nurse LVN D told her not all of Resident #1's medications had been delivered. LVN 676494 Page 2 of 15 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some A said she contacted the pharmacy and gave them a list of the medications that were missing, and they had them delivered that night. LVN A said if a resident was missing medications, they are supposed to call the pharmacy to check on the medications and notify the doctor. LVN A said she did not notify the doctor the medications were not delivered, and Resident #1 missed doses of his seizure medications. LVN A said on Friday, 07/25/2025, Resident #1 had a small seizure. LVN A said she failed to notify the doctor Resident #1 had a seizure. LVN A said she should have notified the doctor, but she did not because she was busy and was sending out a different resident to the hospital when Resident #1 had his seizure. LVN A said it was important to notify the doctor of changes in condition because the doctor may want to order labs and adjust medications. LVN A said not notifying the doctor of changes in condition could result in seizures and hospitalizations. LVN A said not administering medications could result in seizures and high blood pressures that it depended on the medication what adverse effect resulted. During an interview on 07/27/2025 at 11:38 AM, LVN D said when a resident admitted /re-admitted to the facility the admitting nurse was responsible for putting in the orders in the electronic health record. LVN D said the orders should be sent to the pharmacy or they should call the pharmacy to notify them of the resident's admission so the medications could be sent. LVN D said if a resident's medication was not delivered from the pharmacy, they should indicate on the MAR the medication was unavailable and notify the pharmacy and management. LVN D said they should also notify the doctor the medication was not given. LVN D said she did not attempt to order Resident #1's medications until Thursday (07/24/2025) night. LVN D said she had not notified the doctor of Resident #1's missed doses because she thought she did not have to notify the doctor unless 3 doses were missed. LVN D said she tried to document unavailable or not administered for Resident #1's medications that she did not administer. LVN D said depending on the medication that was not administered the residents could have multiple adverse reactions such as high blood pressure and fluid buildup. LVN D said it was important to notify the doctor of missed medications to prevent hospitalizations. During an interview on 07/27/2025 at 12:44 PM, LVN B said all medication were delivered through the facility's pharmacy to the facility. LVN B said if medications were placed in the electronic health record before 3 PM, they would be delivered the same night. LVN B said Resident #1 admitted sometime on the day shift on 07/22/2025. LVN B said Resident #1's medications were not delivered on 07/22/2025. LVN B said she had no idea why Resident #1's medications were not delivered on 07/22/2025. LVN B said she did not work on 07/23/2025 and 07/24/2025. LVN B said on 07/25/2025, when she arrived for her shift, LVN A informed her some of Resident #1's medications had not been delivered, but they would be delivered that night (07/25/2025). LVN B said Resident #1's seizure medications were delivered 07/25/2025 during her night shift, and she was able to administer all of them. LVN B said the doctor should be notified when medications were not available for administration. LVN B said she did not notify the doctor Resident #1 had missed doses of his seizure medications. LVN B said the doctor should have been notified because they were medications that should not be missed, and it placed Resident #1 at risk for seizures and cardiac arrest and it affected the resident's overall health. LVN B said if a resident had a seizure, the doctor, DON, oncoming nurse, and the family should be notified. LVN B said not notifying the physician led to lack of care because the doctor would not know what was going on and it caused a gap in care that the residents needed. During an interview on 07/27/2025 at 1:01 PM, LVN E said the ADONs and DON put in the resident's physician orders into the electronic health record, and from her understanding they went to the pharmacy automatically. LVN E said if there was a new admission they should fax the orders to the pharmacy for the medications to be sent to the facility. LVN E said she worked on 07/23/2025 and 07/24/2025 on the day shift. LVN E said she 676494 Page 3 of 15 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some did not administer any medications to Resident #1 on 07/23/2025 because she sent him to the hospital. LVN E said she was not able to remember if she had signed off the medications as administered in his MAR or as hospitalized . LVN E said she might have inaccurately documented some of Resident #1's medications as administered, when she did not administer them because she was in a rush and had a lot going on. LVN E said 07/24/2025, she contacted the pharmacy about Resident #1's medications, and the pharmacy told her his medications would be delivered Monday (07/28/2025). LVN E said she did not notify the doctor that Resident #1's medications were not delivered and were not administered. LVN E said at the time she was not aware she was supposed to notify the doctor. LVN E said it was important for the doctor to be notified of missed doses of medication to see if he wanted to order something different. LVN E said Resident #1 not receiving his seizure medications could result in him having seizure. During an interview on 07/27/2025 at 1:16 PM, the Pharmacist said the DON contacted them yesterday (07/26/2025) to ask about Resident #1's medications. The Pharmacist said when Resident #1 re-admitted to the facility for whatever reason they did not get the request to send his medications in their system. The Pharmacist said the facility possibly indicated the medications were on hand, which would result in the medications not being sent out to the facility. The Pharmacist said the request for Resident #1's medications was received on 07/25/2025. The Pharmacist said usually the electronic system used by the facility notified them when a resident admitted , and orders were put in because the facility's system was linked with the pharmacy. During an interview on 07/27/2025 at 1:22 PM, the DON said Resident #1 re-admitted on [DATE] or 07/23/2025. The DON said the nurses did not follow the facility's protocol and notify him Resident #1's medications were not delivered. The DON said the nurses should have notified him, so the doctor could be notified. The DON said late Friday evening (07/25/2025) Resident #1's family member notified him Resident #1 had not received his seizure medications, and he informed her the medications would be delivered to the facility that evening. The DON said they started in-services on abuse and neglect, medication errors, instructed the nurses to notify him of medications that were not available and notifying the doctor. The DON said LVN D and LVN E were suspended pending investigation due to them failing to notify the DON that Resident #1's medications were not available and documenting medications as administered when they were not available in the facility. The DON said when a resident admitted to the facility, orders were put into their electronic health system and the pharmacy was notified electronically to send the medications. The DON said LVN A did not notify the doctor of Resident #1's seizure. The DON said he reported it to the doctor when he was notified that Resident #1 had a seizure. The DON said medications not being administered greatly increased the residents' chances of negative outcomes such as increased seizure activity and death. The DON said it was important to notify the doctor of changes in condition because it was the cornerstone of good patient care and so they could have documentation that something was done. During an interview on 07/27/2025 at 1:42 PM, ADON F said when a resident admitted to the facility the medications should be put into the electronic health record and the orders go to the pharmacy automatically. ADON F said when Resident #1 re-admitted to the facility nobody notified the pharmacy of his admission. ADON F said when Resident #1's medications were not delivered, they should have contacted the pharmacy. ADON F said she was not notified by the nurses that Resident #1's medications were not delivered. ADON F said the nurses should have notified the doctor of the medications that were not administered to Resident #1. ADON F said medications not administered as ordered could affect the residents' health, and they could end up dying or having a diminished quality of life. ADON F said when a resident had a change in condition the doctor should be notified. ADON F said it was important to notify the doctor to see if it was a one-time thing or to see if medications 676494 Page 4 of 15 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some needed to be adjusted. During an interview on 07/27/2025 at 2:34 PM, the Regional Compliance Nurse said she had reviewed the admissions/re-admissions to make sure their orders and medications were in the facility on 07/26/2025. The Regional Compliance Nurse said she completed care plan audits to ensure residents receiving anti-convulsant medications had a care plan for them on 07/26/2025. The Regional Compliance Nurse said she reviewed the physician orders of residents who received anti-convulsant medications and verified their medications were in the facility. The Regional Compliance Nurse said the doctor was notified of Resident #1's medication error and he ordered loading doses on Resident #1's seizure medications and labs for Wednesday 07/30/2025. The Regional Compliance Nurse said in-services on change in condition, abuse and neglect, medication errors, following the physician orders, new/admission/readmission ordering medications, seizure management, medication reconciliation, medication administration, and following the doctor's orders and standing orders for labs upon admission were conducted. During an interview on 07/27/2025 2:41 PM, ADON C said when a resident was admitted to the facility the pharmacy received notification of the admission. ADON C said there was some kind of error in their system, and the pharmacy was not notified of Resident #1's admission. ADON C said when a resident had a change in condition the physician should be notified. ADON C said it was important for the physician to be notified of changes in condition for continuation of care and so they addressed the residents' changes in condition. ADON C said she spoke with Resident #1's family member regarding their concerns about Resident #1's seizure medications not being administered. ADON C said she talked to the nurses and started in-services with the nurses. ADON C said if a medication was unavailable the nurses needed to notify the doctor, DON, and pharmacy. ADON C said depending on the type of medication if a medication was not administered it could cause serious effects and the residents' labs could be affected. During an interview on 07/27/2025 at 5:21 PM, the Administrator said when a resident admitted to the facility she expected for the nurses to look at the doctor's orders, call the pharmacy, and let them know what medications the resident needed. The Administrator said if a medication was not available, the nurses should notify the physician and see what the physician wanted to order to replace the medication until the pharmacy filled the order. The Administrator said the nurse was responsible for ensuring the medications were in the facility and nurse management should provide oversight. The Administrator said it was important for the medications to be administered to prevent negative experiences. The Administrator said when Resident #1 returned on 07/22/2025 the nurses were supposed to contact the pharmacy to notify them of his return. The Administrator said the nurses failed to notify the pharmacy. The Administrator said she was notified yesterday morning (07/26/2025), that Resident #1 had not received his seizure medications. The Administrator said she was also notified Resident #1 had a seizure and the physician was not notified. The Administrator said she expected for all changes in condition to be reported to the physician. The Administrator said it was important for the physician to be notified of changes in condition to prevent things from happening such as a seizure. During an interview on 07/27/2025 at 7:45 PM, the Medical Director said he was not notified that Resident #1's seizure medications were not administered. The Medical Director said he was not notified Resident #1 had a seizure. The Medical Director said the facility typically reached out to his NP for orders, but he believed she had not been notified either. The Medical Director said Resident #1 not receiving his seizure medications for a couple days could absolutely cause him to have seizures. The Medical Director said he was surprised Resident #1 only had a small seizure because the missed doses could have resulted in more severe seizures. During an interview on 07/27/2025 at 7:56 PM, the NP said she was not notified Resident #1's seizure medications were not administered or that he had a seizure. The NP said she expected the nurses to notify her if 676494 Page 5 of 15 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some this occurred. The NP said she was in the facility often and typically the nurses notified her Monday-Friday of anything that happened. The NP said Resident #1's seizure medications not being administered could result in him having seizures. Review of In-service documentation indicated the following: No staff will be allowed to take a shift until in-service education is completed. The following in-services were initiated on 07/26/2025 at 10:15 AM by the DON, ADON and regional nurse. Staff were sent the in-services via email to review prior to reporting for their shifts. The training was still ongoing at the time of the investigation. All Staff: Change in Condition and Abuse and NeglectNurses and Medication Aides: Medication Administration, Unavailable medications, Medication Error, Following physician orders, New/Admission/readmission ordering medications, Seizure Management, Medication Reconciliation During an interview on 07/28/2025 at 8:45 AM the Division Director of Clinical Services said Resident #1 originally admitted to the facility on [DATE] but returned to the hospital that same day. She said he did not re-admit until 07/22/2025. She said he went back to the hospital on [DATE] and returned to the facility later that same day. She said the emergency medication kit did not contain any liquid medications but the tablet medications were available. She said the pharmacy did not have one of the liquid medications. She said the physician and DON were not notified of the medications being unavailable for administration. During an interview on 07/28/2025 at 9:05 AM the administrator said the in-services were sent by email to staff to read and then the staff members were required to read and sign the in-service sheets when they physically returned to the facility for work. The signature sheets were verified by the administrator, DON, or ADONs for completion prior to working their shifts. During an interview on 07/28/2025 the Regional Compliance nurse said when it was discovered in the late afternoon on 07/25/2025 medications had not been administered and no one had informed the management of the absence of the medications for Resident #1 she said they immediately began to remedy the situation. She said the resident had multiple admissions/re-admissions to the facility in a short period of time. She said she thought the pharmacy was not sure if the resident was actually in the facility. She said the facility should have called the pharmacy to verify the resident's admission and that the medications could be filled and delivered. She said the pharmacy delivers medications twice a day and if an order can be placed by 6 PM it would be delivered that night around 11 PM. She said the pharmacy had been known to fill and deliver a medication stat (needed immediately). She said the error occurred due to poor communication and follow through. She said Resident #1 admitted on the afternoon of 07/22/2025 and medications had been reviewed and input into the electronic health record. She said apparently the order button was not pushed to send the request to the pharmacy but she was not sure exactly what happened. She said the night nurse (coming on at 6 PM) thought the medications had already been ordered and so she did not order them. She said the admitting nurse was off the next 2 days and would have caught the missed medications the next day, but did not catch the error until her return on 7/25/2025. She said the crushable medications were available from the emergency medication kit. She said they began by auditing physician orders for residents receiving anticonvulsants and for the presence of the medications in the facility. She said the MARs were checked for administration. She said the care plans were audited for seizure medication and updated as needed. She said in-servicing of staff began 07/26/2025. She said 2 nurses were suspended pending the investigation as they had signed the MAR indicating they gave Resident #1 the medications that were not present in the facility. She said other nurses indicated the medications were unavailable but did not notify the DON or physician.During an interview on 07/28/25 at 10:00 AM with RN G said he was provided additional training on many things. He noted Abuse and Neglect, Change of Condition, Medication Administration, Notification of the physician, DON and responsible parties of 676494 Page 6 of 15 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some changes and/or missed medications, ordering of medications and unavailability of medications. He said if their pharmacy did not have a medication available they had 24 hour local pharmacy and they could get their pharmacy to send the prescription there. He indicated a new posting at the nurses' station that listed the 2 local pharmacies available to them. During an interview on 07/28/2025 at 10:05 AM with MDS/LVN H said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:10 AM with LVN J indicated Resident #1 resided n her hall. She said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said Resident #1's medications were present in the facility and she administered them that morning. She verified all his seizure medications had been given. During an interview on 07/28/2025 at 10:15 AM with ADON C said she completed the audit on the medication carts and verified the presence of anticonvulsant medications with the corresponding physician orders on 07/26/2025. She said all medications were present except one medication that would have been needed that evening and was not in the emergency kit. She said she called the pharmacy and it was delivered as a high priority and was available at time of administration. During an interview on 07/28/2025 at 10:17 AM MA K said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they had to make sure medications were available in house and not just mark the MAR as unavailable and go on to the next resident. She said she would report it to her charge nurse if something was not available and they could possibly get it for her out of the emergency kit. She said if she finished a medication card she checked her cart for an extra card and if not in her cart she would go immediately to let the charge nurse know about the medication. She said she was able to re-order medications on her computer. During an interview on 07/28/2025 at 10:20 AM MA L said she was shadowing MA K and had started work last week. She said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:25 AM MA M said she received 5 or 6 in-services on Saturday and 2 more that morning and they included abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they were told to report unavailable meds to the charge nurse, ADON or DON so they could re-order it or possibly get it from the emergency kit. During an interview on 07/28/2025 at 10:30 AM with LVN N said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:35 AM MA O said she received in-services and they included abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they were told to report unavailable meds to the charge nurse, ADON or DON so they could re-order it or possibly get it from the emergency kit. During multiple interviews on 07/28/2025 with general staff from the day shift (6AM-6PM) (Housekeeper P, Housekeeper Q, Housekeeper R, Dietary Manager T, Housekeeping Supervisor U, DA W, [NAME] X, DA FF) from 1:04 PM-1:47 PM indicated they said they had been trained on abuse and neglect and change of condition. They said they were given examples of how to identify a change of condition and report it to the charge nurse. They said the abuse coordinator was the administrator and was who they reported to. During multiple interviews on 07/28/2025 with nurses, CNAs, and Mas from both shifts (6AM-6PM and 6PM-6AM) (CNA S, CNA V, CNA Y, NA Z, HA AA, CNA BB, 676494 Page 7 of 15 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some CNA DD, CNA EE, RN GG, MA HH, MA JJ, LVN KK, RN LL, LVN MM, MA NN, MA OO) from 1:08 PM-2:15 PM indicated they said they had been trained on abuse and neglect, change of condition, medication administration, notification of the physician, DON and responsible parties of changes and/or missed medications, ordering of medications and unavailability of medications.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy was marked as given at 6:00 PM on 07/26/2025 and 12:00 AM and 6:00 AM on 07/27/2025.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day. The 9:00 PM dose on 07/25/2025 was marked as given and the 9:00 AM dose was marked as given on 07/26/2025. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Topiramate 100 mg tablet Give one via G-tube two times a day was marked as given two times on 07/25/2025 and two times on 07/26/2025.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy was marked as given at 10:00 PM on 07/26/2025 and 9:00 AM, 3:00 PM on 07/27/2025 were marked as given. On 07/28/2025 at 12:54 PM, the Administrator was informed of the Immediate Jeopardy and provided the IJ template. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began. 676494 Page 8 of 15 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 (Resident #1) of 10 residents reviewed for pharmacy services. The facility failed to order Resident #1's valproic acid, topiramate, levetiracetam, and lacosamide after he re-admitted on [DATE]. Resident #1 had a seizure on 07/25/25. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization.Findings included: Record Review of Resident #1's face sheet dated 07/27/25 indicated the resident was a [AGE] year-old male with an original admission date of 07/10/2025 and readmission date of 07/22/2025. The resident had diagnoses including acute respiratory failure with hypoxia (a life threatening condition where the lungs cannot adequately oxygenate the blood, resulting in low blood oxygen levels), epilepsy with status epilepticus (a serious neurological condition where seizures are prolonged or occur frequently without recovery between them, posing a risk of brain damage), stroke, and high blood pressure.Record Review of Resident #1's readmission assessment note dated 07/22/2025 indicated there was no BIMS score due to resident's inability to answer questions. Resident #1 was alert but unable to speak due to the presence of a tracheostomy tube (a curved hollow tube inserted into a surgically created opening in the neck to create and airway into the windpipe), he had an indwelling urinary catheter and was incontinent of bowel, required extensive to total assistance for ADLs, he had a feeding tube inserted into his abdomen, and had a cough and abnormal lungs sounds of rhonchi (low-pitched, continuous, and rattling sounds heard during breathing, often described as resembling snoring or gurgling.Record Review of Resident #1's care plan with initiation date 0710/2025 and revised 07/26/2025 indicated the resident had a seizure disorder and interventions included for the facility staff to: administer seizure medication as ordered by the doctor, and seizure documentation should have included location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity.Review of Resident #1's Physician Orders last updated 07/26/25 included: Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy, Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day for epilepsy, Topiramate 100 mg tablet Give one via G-tube two times a day for epilepsy, and Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy.Review of Resident #1's hospital after visit summary dated 07/23/2025 indicated the resident was to receive Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube three times a day, Levetiracetam 100 mg/ml Give 15 ml via G-tube every 12 hours, Topiramate 100 mg tablet Give one via G-tube two times a day, and Valproic Acid 250 mg/5 ml Give 10 ml via G-tube every 8 hours.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy was marked as unavailable for the PM dose on 07/22/2025,the AM dose on 07/23/2025 was blank and not marked as given, the PM dose for 07/23/2025, the AM dose for 07/24/2025 was marked as given, the PM dose for 07/24/2025 was marked as not given and the AM dose on 07/25/2025 was marked as given. There was no reason given for the blank and not given marks.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day. The 9:00 PM dose on 07/22/2025 was marked as unavailable, the 9:00AM on 07/23/2025 was blank and not marked as given, the 9:00 PM dose for 07/23/2025 was marked as given, the 9:00 AM dose for 07/24/2025 was marked as given, the Residents Affected - Some 676494 Page 9 of 15 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 9:00 PM dose on 07/24/2025 was marked as not given, the 9:00 AM dose on 07/25/2025 was marked as unavailable. There was no reason given for the blank and not given marks. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Topiramate 100 mg tablet Give one via G-tube two times a day the AM dose on 07/22/2025 was not marked as given and was blank. There was no reason given for the blank space.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy was marked as unavailable for the 9:00 PM dose on 07/22/2025, the 9:00 AM dose and 3:00 PM doses on 07/23/2025 were blank and not marked as given. The 9:00 AM, 3:00 PM and 9:00 PM doses on 07/24/2025 were marked as given. The 9:00 AM, 3:00 PM and 9:00 PM doses on 07/25/2025 were marked as given. There was no reason given for the blank and not given marks.During an interview on 07/27/2025 at 8:23 AM, Resident #1's family member said she was visiting Resident #1 around 1:00 PM-1:45 PM on 07/25/2025, when he had a seizure. Resident #1's family member said she called the nurse to the room for assistance, and LVN A assessed Resident #1 and told them he would probably be a little sleepy. Resident #1's family member said LVN A told her she would call the doctor to see if he wanted to do any labs. Resident #1's family member said later in the evening of 07/25/2025 she went to check on Resident #1 and was informed by LVN B that Resident #1's seizure medications had not been administered prior to 07/25/2025. Resident #1's family member said LVN B told her his seizure medications had just arrived (07/25/2025). Resident #1's family member said she had LVN B print her Resident #1's medication administration record and his seizure medications were marked as unavailable or administered. Resident #1's family member said the nurses falsified the documentation because the seizure medications were not in the facility. Resident #1's family member said she was very concerned about her family member because he had a history of seizures, and in the past had been hospitalized due to uncontrolled seizures that would not stop. Resident #1's family member said she had contacted the DON and ADON C and explained her concerns regarding Resident #1's seizure medications. Resident #1's family member said the DON told her the pharmacy did not provide the medications because they were out. Resident #1's family member said the DON told her they had ordered the medications on 7/25/2025. During an observation of medication administration on 07/27/2025 starting at 9:08 AM, LVN A administered Resident #1's seizure medications: Lacosamide 10mg/ml give 20 ml 200 mg per g-tube twice daily, date received 7/25/25, 20 ml administered. Valproic Acid 250 mg/5 ml give 10 ml 500 mg via g-tube three times daily, date received 7/25/25, 10 ml administered. Levetiracetam 100 mg/ml give 15 ml 1500 mg per g-tube twice daily, date received 7/25/25, 15 ml administered. Topiramate 100 mg give 1 tab via g-tube two times a day, date received 7/25/25, 1 tab administered.During an interview on 07/27/2025 at 11:00 AM, LVN A said the process for when patients admitted /re-admitted was that they verified the orders with the doctor, and then they carried the orders out. LVN A said when they put the orders in the electronic health record the pharmacy sent the medications the same night. LVN A said she re-admitted Resident #1 on 07/22/2025, and she verified his admission orders. LVN A said she normally tried to call the pharmacy to notify them of admission, but she did not have the time to call because she had two admissions back-to-back. LVN A said she was off the 2 days following Resident #1's admission (did not work on 07/23/2025 and 07/24/2025). LVN A said when she returned to work on 07/25/2025, the night nurse LVN D told her not all of Resident #1's medications had been delivered. LVN A said she contacted the pharmacy and gave them a list of the medications that were missing, and they had them delivered that night. LVN A said if a resident was missing medications, they are supposed to call the pharmacy to check on the medications and notify the doctor. LVN A said she did not notify the doctor the medications were not delivered, and Resident #1 missed doses of his seizure medications. LVN A said on Friday, 676494 Page 10 of 15 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 07/25/2025, Resident #1 had a small seizure. LVN A said not administering medications could result in seizures and high blood pressures that it depended on the medication what adverse effect resulted. During an interview on 07/27/2025 at 11:38 AM, LVN D said when a resident admitted /re-admitted to the facility the admitting nurse was responsible for putting in the orders in the electronic health record. LVN D said the orders should be sent to the pharmacy or they should call the pharmacy to notify them of the resident's admission so the medications could be sent. LVN D said if a resident's medication was not delivered from the pharmacy, they should indicate on the MAR the medication was unavailable and notify the pharmacy and management. LVN D said they should also notify the doctor the medication was not given. LVN D said she did not attempt to order Resident #1's medications until Thursday (07/24/2025) night. LVN D said depending on the medication that was not administered the residents could have multiple adverse reactions such as high blood pressure and fluid buildup. During an interview on 07/27/2025 at 12:44 PM, LVN B said all medication were delivered through the facility's pharmacy to the facility. LVN B said if medications were placed in the electronic health record before 3 PM, they would be delivered the same night. LVN B said Resident #1 admitted sometime on the day shift on 07/22/2025. LVN B said Resident #1's medications were not delivered on 07/22/2025. LVN B said she had no idea why Resident #1's medications were not delivered on 07/22/2025. LVN B said she did not work on 07/23/2025 and 07/24/2025. LVN B said on 07/25/2025, when she arrived for her shift, LVN A informed her some of Resident #1's medications had not been delivered, but they would be delivered that night (07/25/2025). LVN B said Resident #1's seizure medications were delivered 07/25/2025 during her night shift, and she was able to administer all of them. During an interview on 07/27/2025 at 1:01 PM, LVN E said the ADONs and DON put in the resident's physician orders into the electronic health record, and from her understanding they went to the pharmacy automatically. LVN E said if there was a new admission they should fax the orders to the pharmacy for the medications to be sent to the facility. LVN E said she worked on 07/23/2025 and 07/24/2025 on the day shift. LVN E said she did not administer any medications to Resident #1 on 07/23/2025 because she sent him to the hospital. LVN E said she was not able to remember if she had signed off the medications as administered in his MAR or as hospitalized . LVN E said she might have inaccurately documented some of Resident #1's medications as administered, when she did not administer them because she was in a rush and had a lot going on. LVN E said 07/24/2025, she contacted the pharmacy about Resident #1's medications, and the pharmacy told her his medications would be delivered Monday (07/28/2025). During an interview on 07/27/2025 at 1:16 PM, the Pharmacist said the DON contacted them yesterday (07/26/2025) to ask about Resident #1's medications. The Pharmacist said when Resident #1 re-admitted to the facility for whatever reason they did not get the request to send his medications in their system. The Pharmacist said the facility possibly indicated the medications were on hand, which would result in the medications not being sent out to the facility. The Pharmacist said the request for Resident #1's medications was received on 07/25/2025. The Pharmacist said usually the electronic system used by the facility notified them when a resident admitted , and orders were put in because the facility's system was linked with the pharmacy. During an interview on 07/27/2025 at 1:22 PM, the DON said Resident #1 re-admitted on [DATE] or 07/23/2025. The DON said the nurses did not follow the facility's protocol and notify him Resident #1's medications were not delivered. The DON said the nurses should have notified him, so the doctor could be notified. The DON said late Friday evening (07/25/2025) Resident #1's family member notified him Resident #1 had not received his seizure medications, and he informed her the medications would be delivered to the facility that evening. The DON said they started in-services on abuse and neglect, medication errors, instructed the nurses to notify him of 676494 Page 11 of 15 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some medications that were not available and notifying the doctor. The DON said LVN D and LVN E were suspended pending investigation due to them failing to notify the DON Resident #1's medications were not available and documenting medications as administered when they were not available in the facility. The DON said when a resident admitted to the facility, orders were put into their electronic health system and the pharmacy was notified electronically to send the medications. The DON said LVN A did not notify the doctor of Resident #1's seizure. The DON said he reported it to the doctor when he was notified that Resident #1 had a seizure. The DON said medications not being administered greatly increased the residents' chances of negative outcomes such as increased seizure activity and death. The DON said it was important to notify the doctor of changes in condition because it was the cornerstone of good patient care and so they could have documentation that something was done. During an interview on 07/27/2025 at 1:42 PM, ADON F said when a resident admitted to the facility the medications should be put into the electronic health record and the orders go to the pharmacy automatically. ADON F said when Resident #1 re-admitted to the facility nobody notified the pharmacy of his admission. ADON F said when Resident #1's medications were not delivered, they should have contacted the pharmacy. ADON F said she was not notified by the nurses that Resident #1's medications were not delivered. ADON F said the nurses should have notified the doctor of the medications that were not administered to Resident #1. ADON F said medications not administered as ordered could affect the residents' health, and they could end up dying or having a diminished quality of life. During an interview on 07/27/2025 at 2:34 PM, the Regional Compliance Nurse said she had reviewed the admissions/re-admissions to make sure their orders and medications were in the facility on 07/26/2025. The Regional Compliance Nurse said she completed care plan audits to ensure residents receiving anti-convulsant medications had a care plan for them on 07/26/2025. The Regional Compliance Nurse said she reviewed the physician orders of residents who received anti-convulsant medications and verified their medications were in the facility. The Regional Compliance Nurse said the doctor was notified of Resident #1's medication error and he ordered loading doses on Resident #1's seizure medications and labs for Wednesday 07/30/2025. The Regional Compliance Nurse said in-services on change in condition, abuse and neglect, medication errors, following the physician orders, new/admission/readmission ordering medications, seizure management, medication reconciliation, medication administration, and following the doctor's orders and standing orders for labs upon admission were conducted. During an interview on 07/27/2025 2:41 PM, ADON C said when a resident was admitted to the facility the pharmacy received notification of the admission. ADON C said there was some kind of error in their system, and the pharmacy was not notified of Resident #1's admission. ADON C said she spoke with Resident #1's family member regarding their concerns about Resident #1's seizure medications not being administered. ADON C said she talked to the nurses and started in-services with the nurses. ADON C said if a medication was unavailable the nurses needed to notify the doctor, DON, and pharmacy. ADON C said depending on the type of medication if a medication was not administered it could cause serious effects and the residents' labs could be affected. During an interview on 07/27/2025 at 5:21 PM, the Administrator said when a resident admitted to the facility she expected for the nurses to look at the doctor's orders, call the pharmacy, and let them know what medications the resident needed. The Administrator said if a medication was not available, the nurses should notify the physician and see what the physician wanted to order to replace the medication until the pharmacy filled the order. The Administrator said the nurse was responsible for ensuring the medications were in the facility and nurse management should provide oversight. The Administrator said it was important for the medications to be administered to prevent negative experiences. The Administrator said when Resident #1 returned on 676494 Page 12 of 15 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 07/22/2025 the nurses were supposed to contact the pharmacy to notify them of his return. The Administrator said the nurses failed to notify the pharmacy. The Administrator said she was notified yesterday morning (07/26/2025), that Resident #1 had not received his seizure medications. The Administrator said she was also notified Resident #1 had a seizure and the physician was not notified. During an interview on 07/27/2025 at 7:45 PM, the Medical Director said he was not notified that Resident #1's seizure medications were not administered. The Medical Director said he was not notified Resident #1 had a seizure. The Medical Director said the facility typically reached out to his NP for orders, but he believed she had not been notified either. The Medical Director said Resident #1 not receiving his seizure medications for a couple days could absolutely cause him to have seizures. The Medical Director said he was surprised Resident #1 only had a small seizure because the missed doses could have resulted in more severe seizures. During an interview on 07/27/2025 at 7:56 PM, the NP said she was not notified Resident #1's seizure medications were not administered or that he had a seizure. The NP said she expected the nurses to notify her if this occurred. The NP said she was in the facility often and typically the nurses notified her Monday-Friday of anything that happened. The NP said Resident #1's seizure medications not being administered could result in him having seizures. Review of In-service documentation indicated the following: No staff will be allowed to take a shift until in-service education is completed. The following in-services were initiated on 07/26/2025 at 10:15 AM by the DON, ADON and regional nurse. Staff were sent the in-services via email to review prior to reporting for their shifts. The training was still ongoing at the time of the investigation. All Staff: Change in Condition and Abuse and NeglectNurses and Medication Aides: Medication Administration, Unavailable medications, Medication Error, Following physician orders, New/Admission/readmission ordering medications, Seizure Management, Medication Reconciliation During an interview on 07/28/2025 at 8:45 AM the Division Director of Clinical Services said Resident #1 originally admitted to the facility on [DATE] but returned to the hospital that same day. She said he did not re-admit until 07/22/2025. She said he went back to the hospital on [DATE] and returned to the facility later that same day. She said the emergency medication kit did not contain any liquid medications but the tablet medications were available. She said the pharmacy did not have one of the liquid medications. She said the physician and DON were not notified of the medications being unavailable for administration. During an interview on 07/28/2025 at 9:05 AM the administrator said the in-services were sent by email to staff to read and then the staff members were required to read and sign the in-service sheets when they physically returned to the facility for work. The signature sheets were verified by the administrator, DON, or ADONs for completion prior to working their shifts. During an interview on 07/28/2025 the Regional Compliance nurse said when it was discovered in the late afternoon on 07/25/2025 medications had not been administered and no one had informed the management of the absence of the medications for Resident #1 she said they immediately began to remedy the situation. She said the resident had multiple admissions/re-admissions to the facility in a short period of time. She said she thought the pharmacy was not sure if the resident was actually in the facility. She said the facility should have called the pharmacy to verify the resident's admission and that the medications could be filled and delivered. She said the pharmacy delivers medications twice a day and if an order can be placed by 6 PM it would be delivered that night around 11 PM. She said the pharmacy had been known to fill and deliver a medication stat (needed immediately). She said the error occurred due to poor communication and follow through. She said Resident #1 admitted on the afternoon of 07/22/2025 and medications had been reviewed and input into the electronic health record. She said apparently the order button was not pushed to send the request to the pharmacy but she was not sure 676494 Page 13 of 15 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some exactly what happened. She said the night nurse (coming on at 6 PM) thought the medications had already been ordered and so she did not order them. She said the admitting nurse was off the next 2 days and would have caught the missed medications the next day, but did not catch the error until her return on 7/25/2025. She said the crushable medications were available from the emergency medication kit. She said they began by auditing physician orders for residents receiving anticonvulsants and for the presence of the medications in the facility. She said the MARs were checked for administration. She said the care plans were audited for seizure medication and updated as needed. She said in-servicing of staff began 07/26/2025. She said 2 nurses were suspended pending the investigation as they had signed the MAR indicating they gave Resident #1 the medications that were not present in the facility. She said other nurses indicated the medications were unavailable but did not notify the DON or physician. During an interview on 07/28/25 at 10:00 AM with RN G said he was provided additional training on many things. He noted Abuse and Neglect, Change of Condition, Medication Administration, Notification of the physician, DON and responsible parties of changes and/or missed medications, ordering of medications and unavailability of medications. He said if their pharmacy did not have a medication available they had 24 hour local pharmacy and they could get their pharmacy to send the prescription there. He indicated a new posting at the nurses' station that listed the 2 local pharmacies available to them. During an interview on 07/28/2025 at 10:05 AM with MDS/LVN H said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:10 AM with LVN J indicated Resident #1 resided n her hall. She said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said Resident #1's medications were present in the facility and she administered them that morning. She verified all his seizure medications had been given. During an interview on 07/28/2025 at 10:15 AM with ADON C said she completed the audit on the medication carts and verified the presence of anticonvulsant medications with the corresponding physician orders on 07/26/2025. She said all medications were present except one medication that would have been needed that evening and was not in the emergency kit. She said she called the pharmacy and it was delivered as a high priority and was available at time of administration. During an interview on 07/28/2025 at 10:17 AM MA K said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they had to make sure medications were available in house and not just mark the MAR as unavailable and go on to the next resident. She said she would report it to her charge nurse if something was not available and they could possibly get it for her out of the emergency kit. She said if she finished a medication card she checked her cart for an extra card and if not in her cart she would go immediately to let the charge nurse know about the medication. She said she was able to re-order medications on her computer. During an interview on 07/28/2025 at 10:20 AM MA L said she was shadowing MA K and had started work last week. She said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:25 AM MA M said she received 5 or 6 in-services on Saturday and 2 more that morning and they included abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they were told to report unavailable meds to the charge nurse, ADON or DON so they could re-order it or possibly get it from the emergency kit. During an interview on 07/28/2025 at 10:30 AM with LVN N 676494 Page 14 of 15 676494 07/28/2025 Bluebonnet Point Wellness 151 Heritage Springs Drive Bullard, TX 75757

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:35 AM MA O said she received in-services and they included abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they were told to report unavailable meds to the charge nurse, ADON or DON so they could re-order it or possibly get it from the emergency kit. During multiple interviews on 07/28/2025 with general staff from the day shift (6AM-6PM) (Housekeeper P, Housekeeper Q, Housekeeper R, Dietary Manager T, Housekeeping Supervisor U, DA W, [NAME] X, DA FF) from 1:04 PM-1:47 PM indicated they said they had been trained on abuse and neglect and change of condition. They said they were given examples of how to identify a change of condition and report it to the charge nurse. They said the abuse coordinator was the administrator and was who they reported to. During multiple interviews on 07/28/2025 with nurses, CNAs, and Mas from both shifts (6AM-6PM and 6PM-6AM) (CNA S, CNA V, CNA Y, NA Z, HA AA, CNA BB, CNA DD, CNA EE, RN GG, MA HH, MA JJ, LVN KK, RN LL, LVN MM, MA NN, MA OO) from 1:08 PM-2:15 PM indicated they said they had been trained on abuse and neglect, change of condition, medication administration, notification of the physician, DON and responsible parties of changes and/or missed medications, ordering of medications and unavailability of medications. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy was marked as given at 6:00 PM on 07/26/2025 and 12:00 AM and 6:00 AM on 07/27/2025.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day. The 9:00 PM dose on 07/25/2025 was marked as given and the 9:00 AM dose was marked as given on 07/26/2025. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Topiramate 100 mg tablet Give one via G-tube two times a day was marked as given two times on 07/25/2025 and two times on 07/26/2025.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy was marked as given at 10:00 PM on 07/26/2025 and 9:00 AM, 3:00 PM on 07/27/2025 were marked as given. On 07/28/2025 at 12:54 PM, the Administrator was informed of the Immediate Jeopardy and provided the IJ template. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began. 676494 Page 15 of 15