Inspection·June 3, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the right to be free from misappropriation of resident property for one of 1 of 3 (Resident # 2) reviewed for misappropriation. Residents Affected - Few The facility failed to prevent a diversion (misappropriation) of Resident's #2's Ativan 0.5 mg, 60 tablets (an anti-anxiety medication) received from the pharmacy on 5/22/2024 at 12:17 am and reported missing 5/22/2024 during the day shift. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity. The non-compliance was identified as Past non-compliance, the facility had corrected the non-compliance before the survey began. Findings included: Review of Resident # 2's faced sheet printed `5/22/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Alzheimer's disease ( A progressive disease that destroys memory and other important mental functions) , Cognitive communication deficit ( a communication difficulty caused by a cognitive impairment, this impairment can affect any aspect of communication, including verbal and nonverbal language, ,speaking, listening, reading writing and social interaction) and palliative care(specialized medical care for people living with a serious illness) Review of Resident's #2's of admission MDS dated [DATE] revealed a BIMS score of 3 which can indicate a serve cognitive impairment, Resident was receiving hospice care. Review of Resident # 2's physician orders dated 6/3/2024 revealed order written on 5/5/2024 Ativan 0.5 mg Po PRN Q 4 hours for anxiety. Review of the provider investigation report dated 5/31/2024 reflected, on 5/22/2024 at 12: 17 am the pharmacy delivered 60 (sixty) tablets of Ativan 0.5 mg for Resident # 2, packing slip from the pharmacy was signed by LVN A as received. Medication was noticed as missing, on the next shift. A search of the facility's medication rooms and medication carts and the medication was not located. The report reflected no injury or harm to the resident as medication was available in the emergency medication kit and the facility replaced the missing medication after the investigation was completed, the facility notified Hospice, the responsible party, the medical director, and the police. Statements were obtained and staff were drug tested. The investigation findings confirmed the drug diversion. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 675406 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 675406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Years Nursing and Rehabilitation Center 318 Chambers St Marlin, TX 76661 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)