Health inspection·November 8, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure treatment and care was provided in accordance with the comprehensive assessment and professional standards of practice that met the physical, mental and psychological needs for 1 of 6 residents (#10) reviewed for pacemakers in that: Residents Affected - Few The facility did not maintain physician orders and medical information needed to monitor Resident #10's cardiac pacemaker (electronic device that is implanted in the body to monitor heart rate and rhythm that stimulates the heart with electrical impulses to maintain or restore a normal heartbeat) parameters for proper functioning. This failure could place residents of risk for not receiving proper care and treatment. The findings included: Record review of Resident #10's face sheet, dated 06/28/2023 revealed a [AGE] year-old female with an initial admission 4/2/2024 and a readmission on [DATE] with diagnoses of; Chronic Obstructive Pulmonary Disease (lung disease that damages the lungs making it hard to breathe), Atherosclerotic Heart Disease (plaque in heart arteries that reduces blood flow), and Presence of Cardiac Pacemaker. Record review of Resident #10's MDS, dated [DATE] revealed BIMS score of 11, which indicated moderate cognitive impairment. Record review of Resident #10's Care Plan, dated 9/19/2024 revealed, The resident will maintain heart rate within acceptable limits as determined by MD/pacemaker settings . Record review of Resident #10's most recent admission Initial admission assessment, dated 5/31/2023 revealed Pacemaker frequency unknown. Per resident, this is pacemaker number 4. It is managed by a vascular clinic. Record review of Resident #10's Order Summary Report, dated 11/6/2024 did not have orders for pacemaker parameters. Record review of Resident # 10's TAR's for October and November 2024 indicated no vital signs completed for pacemaker parameters. During an interview on 11/8/2024 at 11:46 AM with LVN A - she verified pacemaker placement to resident's upper left chest area. She also verified there was no order in place to monitor pacemaker parameters. (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 4 Event ID: 675489 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 675489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devine Health & Rehabilitation 104 Enterprise Ave Devine, TX 78016 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)