Inspection·October 30, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the medical record was complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for clinical records. The facility failed to document nursing progress notes, assessments, or transfer documents when Resident #1 was transferred to the acute care hospital on [DATE]. This failure could place residents at risk for not receiving appropriate care due to incomplete information in the chart. Findings included: Review of Resident #1's admission MDS assessment, dated 10/04/24, Section A (Identification Information) reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including hypertension (high blood pressure), peripheral vascular disease, (disorder of the blood vessels outside of the heart, often decreased blood flow to the limbs) renal insufficiency (poor kidney function), diabetes mellitus (a condition that affects the way the body processes blood sugar), cerebrovascular accident (stroke), and subacute osteomyelitis right ankle and foot (a chronic infection of bone). Section C (Cognitive Patterns) reflected a BIMS score of 9 indicating moderately impaired cognition. Section M (Skin Conditions) reflected an infection of the foot and surgical wounds. Review of Resident #1's electronic medical record reflected there were no assessments completed on 10/28/24. Review of Resident #1's electronic medical record reflected there were no progress notes written 10/28/24 that reflected the resident's status, a change in status, or an emergent condition that warranted transfer to the acute hospital. There was no progress note that reflected the provider was notified nor an order to transfer to the acute hospital received. Review of Resident #1's electronic medical record reflected there was no physician order to transfer the resident to the acute hospital. Review of Resident #1's electronic medical record reflected a progress note dated 10/28/24 at 9:00 PM, written by LVN A, Ambulance transportation here to take resident to [name] ER. RP notified. During an interview on 10/30/24 at 10:45 AM, the DON stated Resident #1 had wounds, and despite the (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 2 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 10/30/2024 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)