Health inspection·August 3, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Review of Resident #8's EMAR reflected on 6/6/2023 the 10:00 PM dose of Tramadol HCL 50 mg tablet was checked off by VNR. Review of Resident #8's June narcotic count sheet reflected no entries on 6/6/2023 at 10:00 for the Tramadol HCL 50 mg tablet. Residents Affected - Some Resident #12 Review of Resident #12's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Dementia, Major Depressive Disorder, Insomnia, and Disorientation. Review of Resident #12's MDS assessment, dated 05/5/2023, reflected a BIMS of 5 indicating severe cognitive impairment. Review of Resident #12's EMAR reflected on 5/22/2023 the 8:00 PM dose of Lorazepam 0.5 mg tablet was checked off by VNR. Review of Resident #12's May Narcotic count sheet reflected no entries on 5/22/2023 at 8:00 pm for the Lorazepam 0.5 mg tablet. Resident #13 Review of Resident #13's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Dementia (progressive memory impairment), Type 2 Diabetes Mellitus, Major Depressive Disorder, Pain in left shoulder, Pain in right knee, Pain in left ankle, unsteadiness on feet, hear Failure, Pulmonary Hypertension (high blood pressure affecting the lungs) and chronic kidney disease. Review of Resident #13's MDS assessment, dated 06/16/2023, reflected a BIMS of 3 indicating severe cognitive impairment. Review of Resident #13's EMAR reflected on 5/5/2023 and 5/14/2023, the HS dose of Tramadol HCL 50 mg tablet was checked off by tr and ML respectively. Review of Resident #13's May narcotic count sheet reflected no entries for 5/5/2023 or 5/14/2023 at HS for the Tramadol HCL 50 mg tablet. During an interview on 8/3/2023 at 1:05 PM, Resident #6 stated she did not remember missing any doses of medication in July of 2023 She states she was in pain all the time and did not remember if she had more pain on those days or not. During an interview on 8/3/2023 at 1:12 PM, Resident #8 stated she did not remember missing and medications in June of 2023, but she had no idea what medications they give her anyway, so she would not know if one was missing. She stated she was in pain all the time but did not recall if it was worse back in June. During an interview on 8/3/2023 at 1:25 PM, Resident #12 stated she did not remember any issues with her medications back in May of 2023 and does not remember if she felt more anxious that usual at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675103 If continuation sheet Page 2 of 4 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 675103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Rehabilitation and Healthcare Center 220 Davenport St Italy, TX 76651 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 that time, as it was several months back. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/3/2023, 1:30 PM, Resident #13 stated she did not recall any issues with medications back in Ma y of 2023 but that was too long to remember. She stated she would not know if they left out her pain medication anyway, because she could not identify it. She did not recall whether she was in pain back in May, it was too long ago. Residents Affected - Some During an interview with the DON on 8/3/2023 at 11:30 am, she provided a list of names and phone numbers of the staff that had EMAR discrepancies. She identified AMP as LVN #1, medo as LVN #2, VNR as LVN#3, tr as agency nurse #1 and ML as agency nurse #2. During an interview on 8/3/2023 at 12:20 PM, LVN #1 stated her initials in the EMAR were AMP. When shown the EMAR check off on Resident #6 for the 4:00 PM dose of Tramadol HCL 50 mg tablet on 7/16/2023 and the July narcotic count book, she stated There is no entry there referring to the narcotic count book. She stated, I have no idea what happened; I guess I was in a hurry. She stated she had been working a double shift that day and she may have clicked it off in the EMAR before she gave the medication. She stated the resident could have been sleeping and that is why she had not given it. When asked if she followed the facility policy on documentation for medication administration she stated, Of course not. She stated they are not supposed to click it off on the EMAR until they give the medication She stated if residents did not get their pain medication they could be in severe pain. During an interview on 8/3/2023 at 12:25 PM, LVN #2 stated her initials in the EMAR were medo. When shown the EMAR check off on Resident #6 for the 4:00 PM dose of Tramadol HCL 50 mg tablet on 7/15/2023 and the July narcotic count book, she stated I clicked it off, but didn't give it. I made a mistake. She stated, I don't normally pass meds and she did not have a definite answer as to why there was a discrepancy. She stated she would normally click it off in the EMAR after she had given it, but stated she probably had not given it, ifit if it was not signed out on the narcotic count sheet. She also stated she did not follow facility policy for medication administration, and she really did not remember what happened that day, but she probably had not given it. When asked what could happen if residents did not get their pain medications she stated, the resident could be in pain. During an interview on 8/3/2023 at 1:45 PM, Agency Nurse #1 stated her initials in the EMAR were tr. When shown the EMAR check off on Resident #13 for the HS dose of Tramadol HCL 50 mg tablet on 5/5/2023 and the May narcotic count sheet, she stated that she did not remember what happened that day but if I clicked it in the EMAR, I probably gave it; maybe I put it on the wrong count sheet. She stated, I can't defend myself, but I'm pretty sure I gave it. She stated if residents did nott get their pain medication they could be in pain, and their blood pressure could go up if their pain wasn't alleviated. During an interview on 8/3/2023 at 2:15 PM, LVN #3 stated her initials in the EMAR are VNR. When shown the EMAR check off on Resident #8 on 6/6/2023 for the 10:00 PM dose of Tramadol HCL 50 mg tablet and Resident #12 on 5/22/2023 for the 8:00 PM dose of Lorazepam 0.5 mg tablet and the May and June narcotic count sheets, she stated she thought she had given it but did not remember. She stated she did not know if there was another count sheet but if she had given it she would have signed out for it on the narcotic count sheet where the others were. She said there was a possibility that she did not give the medications, but she did not know where else it would be documented. She stated she was supposed to give the medications then click it off in the EMAR and sign it out on the narcotic count sheets. She stated if residents did not get their pain meds they could have pain and if they do nott get their anti-anxiety meds (Lorazepam) they could get anxious. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675103 If continuation sheet Page 3 of 4 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 675103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Rehabilitation and Healthcare Center 220 Davenport St Italy, TX 76651 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 - Some Agency Nurse #2,ML was contacted by phone three times on 8/3/2023 but had never returned any calls prior to exit on 8/3/2023. During an interview with the DON and the AD on 8/3/2023 at 10:21 am regarding the discrepancies between the EMAR and the narcotic count sheets, the DON stated, I'm thinking they just signed off on it and didn't give it. She further stated a checkmark on the EMAR indicated a medication was given, but if there was no entry on the narcotic count sheets, it had not been given. The DON stated her expectation was staff would give meds as ordered. The AD stated she didn't know too much about EMARs and narcotic count sheets. She stated her and the DON had previously conducted an audit of the narcotic count sheets after a staff expressed a concern and had not found any discrepancies. During an interview on 8/3/2023 at 4:15 PM, the MD stated he was not aware of any discrepancies between EMARS and narcotic count sheets at the facility. He stated they would have discussed discrepancies during their QAPI meetings, and these had not been previously discussed. He started his expectations were that staff would follow orders as given and if they do not it is a med error and should be reported. He stated he had not been notified of any med errors or meds not given. He stated if a resident did not get their prescribed Lorazepam they could have withdrawal symptoms, could have jitters, increased anxiety, or other side effects. He further stated if residents did not get their pain medications as ordered they could have increased pain and possible withdrawal symptoms if they take it on a regular basis. Review of facility policy Administering Medications revised April 2019 reflected 4. Medications are administered in a safe and timely manner, and as prescribed. Also reflected, 22. The individual administering the medication initials the residents MAR on the appropriate line after giving each medication and before administering the next ones. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675103 If continuation sheet Page 4 of 4