Health inspection·April 27, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for one (Resident #2) of 15 residents reviewed for care plans. The facility failed to identify Resident #2's preference for wearing a hospital gown daily instead of her personal clothing. This failure put residents at risk for their preferences not to be honored and decreased quality of life. Findings included: Review Resident #2 Face sheet dated 04/27/2023 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the following diagnosis Cataract (a clouding of the lens of the eye or of its surrounding transparent membrane that obstructs the passage of light), Chorioretinal scars (a pigmentary change in the back of the eye that may result from an infection, injury, or inflammation), and Vitreous degeneration (a change or deterioration of the vitreous humor, the gel-like substance that fills the inside of the eye and helps with vision and eye shape). Review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 12 to indicate mild cognitive impairment. Resident #2 required extensive assistance by one staff member for dressing and personal hygiene. Review of Resident #2's care plan dated 03/10/2023 revealed Resident #2 required staff to assist me to choose simple comfortable clothing that enhances the resident's ability to dress self. Review of care plan did not include Resident #2's preference to wear a hospital gown instead of her personal clothing. In an observation and interview on 04/25/2023 at 9:57 AM, Resident #2 was in her wheelchair wearing a hospital gown. Resident #2 stated she just had a shower and said she asked to wear the hospital gown. Resident #2 pointed at her clothes in the cabinet in her room and said she had clothes but liked to wear the hospital gown because it was more comfortable. In a follow-up observation on 04/26/2023 at 9:10 AM, Resident #2 wore a hospital gown while watching TV in her room. Page 1 of 11 675406 675406 04/27/2023 Golden Years Nursing and Rehabilitation Center 318 Chambers St Marlin, TX 76661

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 04/26/2023 at 10:00 AM, the DON stated she was new to the facility and unsure of whether it was Resident #2's preference to wear a hospital gown or not. She stated she would check with staff and her documentation. She stated Resident #2 did have her own clothing to wear. In an interview on 04/27/2023 at 10:13 AM, CNA J stated Resident #2 preferred to wear a hospital gown because it was more comfortable for her. She stated Resident #2 said it made her feel cooler and Resident #2 felt like her clothes were too restrictive. She stated she was not sure if Resident #2's preference for a hospital gown was included on her care plan. In a follow-up interview on 04/27/2023 at 11:30 AM, the DON stated it was Resident #2's preference to wear a hospital gown instead of her clothing. She stated Resident #2's preference to wear a hospital gown was not on her care plan. She stated Resident #2's preference for wearing a hospital gown instead of her personal clothing should be on the care plan so anyone caring for Resident #2 knew that it was Resident #2's preference. She stated adding Resident #2's preference to wear the hospital gown to her care plan ensured the facility was not violating any dignity issues for Resident #2. In an interview on 04/27/2023 at 11:55 AM, the MDS NURSE stated Resident #2's preference for wearing a hospital gown over Resident #2's personal clothing should have been added to Resident #2's care plan. She stated she was not made aware of Resident #2's preference until recently and had not had a chance to add the information to Resident #2's care plan. She stated anytime there was change for a reference that affected their including resident preferences she tried to update their care plan immediately or within a day or two to ensure continuity of care among caregivers . She said not updating a residents care plan could result in confusion for a resident's preferences and needs not being met. Review of Care Plans, Comprehensive Person-Centered Policy dated Quarter 3 2018 revealed a comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It further revealed the care planning process will . Incorporate the resident's personal and cultural preferences in developing the goals of care. 675406 Page 2 of 11 675406 04/27/2023 Golden Years Nursing and Rehabilitation Center 318 Chambers St Marlin, TX 76661

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of one resident reviewed for catheter care (Resident #11). The facility failed to ensure Resident #11's catheter was secured to his body with a catheter secure device. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections. Findings Included: Review of Resident #11's Face sheet dated 04/27/2023 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following muscle wasting and atrophy (Loss of muscle leading to its shrinking and weakening.), Diabetes Mellitus Type II (a chronic disease where the body has high blood sugar, insulin resistance, and relative lack of insulin), Pressure ulcer of Sacral Region. Review of Resident #11's Significant change in status MDS dated [DATE] reflected Resident #11 was assessed to have a BIMS score of 9 indicating he had mild cognitive impairment. Resident #11 was further assessed to require extensive assist with all ADLs. Resident #11 was assessed to have an indwelling catheter. Review of Resident #11's Care Plan reflected a focus area initiated on 01/27/2023 and revised on 04/21/2023 Alteration in elimination of bowel and bladder related to incontinent of bowel and indwelling foley catheter, has history of UTI and the potential for recurrence. Interventions included .Anchor catheter, avoid excessive tugging on the catheter during transfer and delivery of care . Review of Resident #11's History and Physical dated 03/17/2023 reflected Resident #11 had history of chronic foley catheter and history of penis damage from foley. Observation on 04/26/2023 at 2:00 PM revealed Resident #11 in room in bed. Resident #11 had a Foley Catheter in place without a device to secure the catheter to his leg. Observation and interview on 04/27/2023 at 9:29 AM revealed Resident #11 in room in bed. Observation with the DON revealed resident with no catheter secure device was in place. Further observation revealed Resident #11's meatus and glans (penis) were split from the tip of the glans to base. The DON stated the resident should have a catheter secure device in place in prevent further injury to his glans. The DON stated it was the nurse on duty responsibility to ensure catheter care is done and to ensure the catheter secure device is in place . In an interview on 04/27/2023 at 9:49 AM LVN A stated she was responsible for catheter care and to ensure catheter secure devices are in place. LVN A stated she did not notice that Resident #11 did not have a catheter secure device in place. LVN A stated there should have been one but usually they have an order for it, and she did not see one . 675406 Page 3 of 11 675406 04/27/2023 Golden Years Nursing and Rehabilitation Center 318 Chambers St Marlin, TX 76661

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview 04/27/2023 at 9:51 AM the DON stated the nursing staff should ensure the catheter secure devices are in place for residents with indwelling urinary catheters and the devices should be checked regularly. The DON further stated that the lack of the catheter secure device could cause further penis damage and or infections. Review of the facility's policy Catheter Care, Urinary dated 3rd Quarter 2018 reflected The purpose of this procedure is to prevent catheter-associated urinary tract infections .Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site (Note: Catheter tubing should be strapped to the resident's inner thigh.) . 675406 Page 4 of 11 675406 04/27/2023 Golden Years Nursing and Rehabilitation Center 318 Chambers St Marlin, TX 76661

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater for when the facility had a medication error rate of 20% based on 7 of 35 opportunities, which involved 3 of 5 residents (Resident #2, Resident #11, and Resident #22) and 1 of 3 LVN's (LVN A) observed during medication administration. Residents Affected - Some A) Resident #2 had a physician order for Preser Vision AREDS 2 capsule one by mouth two times daily and Probiotic capsule one capsule by mouth one time day for loose stools. LVN A failed to administer the medications. B) Resident #11 had a physician order for Potassium Chloride Oral Packet 20 MEQs give 2 packets by mouth two times daily and Probiotic capsule one by mouth three times daily. LVN A failed to administer the medications. C) Resident #22 had a physician order for Lisinopril 10 mg by mouth one time day, Aspirin 81mg chewable tablet one time daily, and Probiotic capsule one by mouth daily. LVN A failed to administer the medications. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications. Findings Include: A) Review Resident #2 Face sheet dated 04/27/2023 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the following diagnosis Cataract (a clouding of the lens of the eye or of its surrounding transparent membrane that obstructs the passage of light), Chorioretinal scars (a pigmentary change in the back of the eye that may result from an infection, injury, or inflammation), and Vitreous degeneration (a change or deterioration of the vitreous humor, the gel-like substance that fills the inside of the eye and helps with vision and eye shape). Review of Resident #2's Quarterly MDS dated [DATE] reflected Resident #2 was assessed to have a BIMS score of 12 indicating mild cognitive impairment. Resident #2 was assessed to require extensive to dependent assist with all ADLs. Review of Resident #2's Comprehensive Care Plan reflected a focus area dated 04/14/2021 Resident has impaired visual function related diagnosis of glaucoma and history of cataracts Review of Resident #22 Consolidated Physician dated 04/27/2023 reflected an order for PreserVision AREDS 2 capsule one by mouth two times daily and Probiotic capsule one capsule by mouth one time day for loose stools. Observation on 04/26/2023 at 8:33 AM revealed LVN A preparing Resident #2's 9:00 AM medication for administration. The medications included the following: -Myrbetrig 50 mg ER on e tab -Docusate Sodium 100 mg one capsule 675406 Page 5 of 11 675406 04/27/2023 Golden Years Nursing and Rehabilitation Center 318 Chambers St Marlin, TX 76661

F 0759 -Fexofenadine Hydrochloride 180 mg one tablet Level of Harm - Minimal harm or potential for actual harm -Vitamin D3 25mcg (1000 IU) two tabs -Multi vitamin with minerals one tab Residents Affected - Some -Tussin DM Liquid 10-200mg/ML 10 MLS LVN A did not administer Resident #2's PreserVision AREDS 2 capsule one by mouth two times daily and Probiotic capsule one capsule by mouth one time day for loose stools. B) Review of Resident #11's Face sheet dated 04/27/2023 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following muscle wasting and atrophy (Loss of muscle leading to its shrinking and weakening.), Diabetes Mellitus Type II (a chronic disease where the body has high blood sugar, insulin resistance, and relative lack of insulin), Pressure ulcer of Sacral Region. Review of Resident #11's Significant change in status MDS dated [DATE] reflected Resident #11 was assessed to have a BIMS score of 9 indicating he had mild cognitive impairment. Resident #11 was further assessed to require extensive assist with all ADLs. Review of Resident # 11's Consolidated Physician dated 04/27/2023 reflected an order for Potassium Chloride Oral Packet 20 MEQs give 2 packets by mouth two times daily and Probiotic capsule one by mouth three times daily. Observation on 04/26/2023 at 8:40 AM revealed LVN A preparing Resident #11's 9:00 AM medication for administration. The medications included the following: -Pro-state liquid 30 ML -Ciprofloxacin 500 mg one tablet -Hydrocodone/ Apap 5-325mg one tablet -Gabapentin 300 mg one tablet -Famotidine 20 mg tablet -Amlodipine 5mg one tablet -Labetalol 100 mg one tablet - Decubi-Vit oral capsule one tablet LVN A did not administer Resident #11's Potassium Chloride Oral Packet 20 MEQs give 2 packets by mouth two times daily and Probiotic capsule one by mouth three times daily. C) Review of Resident #22's Face sheet reflected a [AGE] year-old female admitted on [DATE] with the following diagnosis of Alzheimer's disease (A type of brain disorder that causes problems with 675406 Page 6 of 11 675406 04/27/2023 Golden Years Nursing and Rehabilitation Center 318 Chambers St Marlin, TX 76661

F 0759 Level of Harm - Minimal harm or potential for actual harm memory, thinking and behavior. This is a gradually progressive condition.), Atherosclerotic heart disease (A condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall. Symptoms vary depending on the clogged artery.), and Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache). Residents Affected - Some Review of Resident #22 Quarterly MDS dated [DATE] reflected Resident #22 was assessed to have a BIMS score of 4 indicating serve cognitive impairment. Resident #22 was further assessed to require extensive assist with all ADLs. Resident #22 was assessed to have coronary artery disease and Hypertension. Review of Resident #22's Comprehensive Care Plan reflected a focus area dated 09/05/2018, Resident has coronary artery disease interventions included Give all cardiac meds as ordered by the physician .Give meds for hypertension . Review of Resident #22 Consolidated Physician dated 04/27/2023 reflected an order for Lisinopril 10 mg by mouth one time day, Aspirin 81mg chewable tablet one time daily, and Probiotic capsule one by mouth daily. Observation on 04/26/2023 at 9:14 AM revealed LVN A preparing Resident #22's 9:00 AM medication for administration. The medications included the following: -Decubi-Vit one tablet -Buspirone 10mg one tablet -Eliquis 5mg one tablet -Hydroxyzine HCL 25 mg one tablet -Fluoxetine 10 mg one tablet -Memantine HCL 10 mg tablet LVN A did not administer Resident #22's Lisinopril 10 mg by mouth one time day, Aspirin 81mg chewable tablet one time daily, and Probiotic capsule one by mouth daily. In an interview on 10:38 AM LVN A stated after reviewing the medications given to Resident #2 that she did not administer her physician ordered PreserVision AREDS 2 or Probiotic capsule. LVN further stated after reviewing the medications given to Resident #11's that she did not administer his physician ordered Potassium Chloride or Probiotic capsule. LVN A further stated after reviewing the medications given to Resident #22 that she did not administer her physician ordered Lisinopril, Aspirin, or Probiotic. LVN A stated she thought she was checking off all the medications as she went but she must have missed some of the medications because she was nervous. In an interview on 04/26/2023 at 10:41 AM the DON stated she reviewed all the missed medications with LVN A. The DON stated LVN A stated she missed the medications and was not sure how. The DON stated she expected nurses who pass medication to follow the 10 rights of medication administration and to administer all the medications the resident's physician ordered . 675406 Page 7 of 11 675406 04/27/2023 Golden Years Nursing and Rehabilitation Center 318 Chambers St Marlin, TX 76661

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of LVN A's Licensed Nurse orientation/ Annual Skills/ Competency Checklist dated 05/18/2022 reflected she was checked off to have successfully completed Medication Administration. In an interview on 04/26/2023 at 1:46 PM the RNC stated he could not see how LVN A missed all those medications for Resident #2, #11 and #22 during her med pass when she could see them in PCC . The RNC stated he started an action plan and would re-train LVN A. Review of the facility's policy Administering Medications dated quarter 3 2021 reflected Medications shall be administered in safe and timely manner and as prescribed .medications must be administered in accordance with the orders, including any required time frame .The individual administering the medications must check the label carefully to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication . 675406 Page 8 of 11 675406 04/27/2023 Golden Years Nursing and Rehabilitation Center 318 Chambers St Marlin, TX 76661

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and include the appropriate expiration dates for 1of 2 medication rooms and 2 of 4 medication carts reviewed for medication storage. -The facility failed to date a multi-use product (eye drops) when the product was first opened according to manufacture and professional standards. -The facility failed to ensure expired medications were removed from the medication carts and medication rooms. -The facility failed to ensure medications were stored in a clean, safe, and sanitary manner. These failures place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication. Findings Included: Observation on 04/25/2023 at 2:57 PM revealed the facility North Medication room with a bottle Of Vitamin

E 1000 IU with an expiration date of 07/2022. Observation on 04/25/2023 at 3:00 PM revealed the North Medication cart with a bottle of Aspirin 325mg with an expiration date of 09/2022. Observation further revealed Resident #22's Latanoprost eye drops open without an open date and Resident #30's bottle of artificial tears eye drops open with no open date. Observation on 04/25/2023 at 3:10 PM revealed the South Medication cart with an open bottle of Lactulose with a sticky liquid on both sides of the bottle. When the bottle of lactulose was pulled out the cart a box of Mucinex, Imodium and AZO Cranberry tablets were stuck to the side of the bottle with the sticky liquid in and on the boxes of medication that were stuck to the Lactulose bottle. In an interview on 04/25/2023 at 3:15 PM the DON stated that eye drops should be labeled with an open date when they are opened. The DON further stated that all medications on the carts should have readable labels with medications stored in a manner that keeps them clean and dry. The DON and carts should be checked by the Nurses during the medication pass to ensure no expired medications are on the carts to ensure residents are not receiving expired medications to might have altered therapeutic effects. Review of the facility's Policy Storage of Medications dated April 2021 reflected The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed . 675406 Page 9 of 11 675406 04/27/2023 Golden Years Nursing and Rehabilitation Center 318 Chambers St Marlin, TX 76661

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a therapeutic diet as prescribed by the attending physician for one (Resident #15) of eight residents reviewed for therapeutic diet. The facility failed to provide Resident #15 with the therapeutic diet as prescribed by her attending physician when she was provided a meal with extra carbohydrate portions when she was prescribed a consistent carbohydrate diet order. This failure put residents at risk for health complications related to in adherence to diet order, increased blood sugar and decreased quality of life. Findings included: Review of Resident #15's Face Sheet dated 04/27/2023 revealed Resident #15 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnoses of pulmonary disease (disease of the lungs that causes trouble breathing), type 2 diabetes, high blood pressure, bipolar disorder (mood disorder in which mood alternates from manic to depression) and arthritis. Review of Resident #15's quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS score of two to indicate severely impaired cognition. Resident #15 was noted to required a therapeutic diet. Review of Resident #15's Care Plan dated 06/23/2022 revealed Resident #15 had diabetes mellitus with the goal of no complication related to diabetes through review date. Resident #15 had interventions including dietary consult for nutritional regimen and ongoing observation, discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan and compliance with nutritional regimen. Review of Resident #15's Physician Orders dated 03/15/2023 revealed Resident #15 was ordered a Consistent Carbohydrate diet, regular texture and regular consistency. In an observation on 04/25/2023 at 12:25 PM, Resident #15 was in the dining room eating a dinner roll. Additionally on Resident #15's tray there were two pieces of fried fish, white rice and pasta salad. Review of Resident #15's tray card dated 04/25/2023 revealed Resident #15 received CCHO (Consistent Carbohydrate) diet, Finger Foods and thin liquids. In an interview on 04/27/2023 at 11:18 AM, the DM stated Resident #15 received the pasta salad as a finger food selection as it would be easier for Resident #15 to feed herself than the zucchini or rice offered with the regular meal. When asked if the rice, pasta salad and dinner roll included with the meal was consistent with a CCHO diet order, she said no the pasta salad should have been substituted for the rice and an alternative offered with the meal besides a starch. She stated Resident #15 received more carbohydrates with her meal that residents with a regular diet order. In an interview on 04/27/2023 at 11:30 AM, the DON stated the therapeutic diet for Resident #15 675406 Page 10 of 11 675406 04/27/2023 Golden Years Nursing and Rehabilitation Center 318 Chambers St Marlin, TX 76661

F 0808 Level of Harm - Minimal harm or potential for actual harm should have been followed in that Resident #15 was ordered a consistent carbohydrate diet and should be served less carbohydrates than residents on a regular diet. She stated the addition of pasta salad with rice, fried fish and a dinner roll was consistent with professional guidelines for a consistent carbohydrate diet order. She stated failure to serve the physician ordered therapeutic diet could result in Resident #15 experiencing high blood sugar and poor control of Resident #15's diabetes mellitus. Residents Affected - Few In an interview on 04/27/2023 at 11:41 AM, the RD stated she could not determine whether Resident #15 was served the physician ordered consistent carbohydrate diet when she was served pasta salad, rice, fried fish and a dinner roll . She said she did not know if the food served was consistent with professional guidelines for a consistent carbohydrate diet. She stated she did not know if serving more starch food choices to a resident on a consistent carbohydrate diet than residents on a regular diet was within professional guidelines. She stated she did not know what the outcome might be if a diabetic resident was served more starch foods than a resident on a regular diet that is not diabetic. Review of Resident #15's quarterly Nutrition assessment dated [DATE] revealed Resident #15 was ordered a consistent carbohydrate diet (CCD) with no significant weight gain or loss recently. Review of Diet Abbreviations and textures (undated) revealed CCHO-Consistent Carbohydrate-Diabetic-No sugar. 675406 Page 11 of 11