Inspection·November 19, 2023

F 0842 11/8/23 at 10am. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's electronic health record revealed a [AGE] year-old female, admission date 9/8/2023, Diagnoses: malignant neoplasm of pancreas (cancer in organ lying behind the lower part of the stomach), chronic obstructive pulmonary disease (lung diseases that block airflow and make it difficult to breathe), atherosclerotic heart disease of native coronary artery without angina pectoris (plaque buildup in the wall of the arteries that supply blood to the heart), depression (persistent feeling of sadness and loss of interest), hyperlipidemia (high levels of lipids in the blood), essential (primary) hypertension (high blood pressure), acute kidney failure, hypothyroidism (underactive thyroid), anemia (blood doesn't have enough healthy red blood cells), major depressive disorder, anxiety disorder (feelings of worry and fear that interfere with daily activities), insomnia (sleep disorder). Residents Affected - Some Record review of Resident #2's Controlled Drug Record undated for Norco 5/325mg , (physician's order: 1 tablet orally every 8 hours as needed for pain) revealed 1 given on 10/14/23 at 10pm, 1 given on 10/24/23 at 10pm, 1 given 10/25/23 at 5pm, 1 given 10/26/23 at 3pm, 1 given 10/27/23 at 308pm, 1 given 10/28/23 at 11pm, 1 given 11/1/23 at 210pm and 1 given 10pm, 1 given 11/2/23 at 220pm and 10pm. Record review of Resident #2's eMAR for October 2023 revealed no amount given or documented for Norco 5/325mg, 1 tablet orally every 8 hours as needed for pain for 10/14/23 at 10pm, 10/24/23 at 10pm,10/25/23 at 5pm,10/26/23 at 3pm, 10/27/23 at 308pm, 10/28/23 at 11pm. Record review of Resident #2's eMAR for November 2023 for no amount given or documented for Norco 5/325mg, 1 tablet orally every 8 hours as needed for pain for 11/1/23 at 210pm or 10pm, 11/2/23 at 220pm or 10pm. Interview on 11/17/23 at 4:52 pm with LVN-A revealed he was to document medications administered in the patient's MARs. LVN revealed he has the computer (for eMAR) and the notebook and narc sheet (Controlled Drug Record) that he uses to document vital signs and all meds administered. Interview on 11/19/2023 at 12:03 pm with the ADON revealed during the facility's drug diversion investigation, the facility looked at administration records and sheets and found multiple pain pills given that did not add up. The facility had residents that rarely took these pills and then all of a sudden on the terminated employees shift, the residents were supposedly taking more than double. These were uninterviewable residents, but staff reported no change in condition to include the increase. After this incident, staff monitored these residents more closely and there was actually no change in condition. Interview on 11/19/23 at 1:22pm with the DON revealed the facility did an audit on 11/3/2023 on the MARs documentation and did a retraining to all staff on 11/3/2023. The DON provided the MARs and the narc sheets and revealed that the terminated employee documented on the narc sheet but not on the MARs. The night nurse stumbled upon the drug discrepancy because she had just counted that before it was signed in a few days before. Interview on 11/19/23 at 3:47 pm with the ADM revealed the ADON's should be checking documentation daily to check for omission. The ADM did not answer when asked what could happen to the resident. The ADM stated, I know what you are saying and revealed they have put new procedures in place to prevent this from happening again. The MARs will be audited twice a week and have them document the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455931 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 455931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Vernon 4401 College Dr Vernon, TX 76384 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 number on the narcotic sheet, as well. Level of Harm - Minimal harm or potential for actual harm Record review of the Drug Diversion Guidelines policy dated 2/23/2017 revealed the following recommendations are designed to reduce and limit drug diversion: .8). Document usage both on MARs and narcotic count sheet as soon as possible after administration. 9). Document administration of PRNs controlled substances on the MARs including dose, date, time, route, and effectiveness of medication. Residents Affected - Some Record review of the Medication-Treatment Administration and Documentation Guidelines dated 4/6/2023 revealed Process: .5). Document e-signature for medications and treatments administered on the EMAR immediately following administration. 6). When a controlled medication is administered .enter the following information on the accountability record .; date and time of administration, amount administered, signature of the nurse administering the dose. (Also document controlled medication dose administered on the eMAR). 11). Document PRN medication and treatment administered on the EMAR or ETAR along with the reason immediately following administration. Document effectiveness of the intervention on the EMAR as indicated. 12). Review the EMAR and ETAR after each medication and treatment administration is completed and prior to the end of the shift to validate documentation is completed and support services provided according to physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455931 If continuation sheet Page 3 of 3