Inspection·August 28, 2023

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with diagnoses including: Spinal Stenosis, lumbar region (narrowing of the spinal canal in the lower back), dysphagia (trouble swallowing), Major Depressive disorder. Record review of an Annual MDS dated [DATE] for Resident #4 indicated that she had a BIMS score of 15, indicating that she was cognitively intact. She was documented as receiving an opioid daily for the entire 7 day look back period. Record review of physician's orders dated 4/30/23for Resident #4 indicated that he had an active order for oxycodone 5mg, 1 tablet by mouth every 3 hours. Record review of a medication administration record for Resident #4 for the month of July 2023 indicated the resident received oxycodone every 3 hours as needed until the order was discontinued on 7/25/23. During an interview and observation on 8/28/23 beginning at 11:10 am with MA A said she had worked at the facility since 1986. She said the morning of 7/6/23 she noticed that a pain medication had been signed out as given the day before, but she knew the resident had refused the medication the day before. She said that if she counted the cart when coming on shift and the count was off, she would let the off going nurse know so she could correct the count before leaving her shift. She said it was frequent that RN A would not sign out the narcotics until the cart was counted. She said she did report it on the day of 7/6/23 to the DON. She said the procedure for counting the cart was the oncoming person counted the pills and the off going person looked at the count sheet to make sure the count was correct. The B side cart was counted, and the correct count was observed. She said she had been inserviced regarding a drug free workplace, and drug diversions and was able to verbalize understanding of the policy and procedures. A phone call was attempted on 8/28/23 at 11:20 am with RN A, but there was no answer and surveyor was unable to leave a voicemail. During an observation and interview on 8/28/23 beginning at 11:25 am with RN C said she works for the facility as needed. She said she had relieved RN A at times and sometimes the count would not be correct. She said RN A would sign out for the narcotics and the count would be correct before she assumed responsibility for the cart. She said that it happened a lot, but she assumed RN A just forgot to sign out the narcotics that she had administered. She said the procedure for counting the cart had always been, the oncoming person counted the pills and the off going person looked at the count sheet to make sure the count was correct. The cart was counted, and the correct count was observed. She said she had been inserviced regarding a drug free workplace, and drug diversions and was able to verbalize understanding of the policy and procedures. During an interview on 8/28/23 at 1:20 pm, the DON said that on 7/6/23 RN A was late to work so she had to work the floor until RN A arrived. She said she told RN A there was a problem with the narcotic count, but she would talk to her about it later. She said she began investigating the narcotic counts and found some discrepancies and notified the administrator. During an interview on 8/28/23 at 4:00 pm the Admin said on 7/6/23 it was reported to her that a narcotic medication that had already been signed out on the count sheet was signed out again by RN A. She said RN A told her she had signed out medication on Resident #1 to give to different resident because the other resident was out of medication. The Admin said RN A told her she knew she was not supposed to do that but she had done it anyway. The Admin said she drug tested RN A on 7/5/23 and RN A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675624 If continuation sheet Page 2 of 3 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 675624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall Rehab & Nursing 1116 E Loop 304 Crockett, TX 75835 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tested positive for PCP (Phencyclidine an illegal street drug). The Admin said she suspended RN A pending investigation at that time. She said the investigation revealed RN A had signed out medications for Resident #4 while Resident #4 was in the hospital on 7/5/23. She said she told RN A to come to the facility on 7/10/23 at 8:30 am but RN A did not show up. Record review of individual narcotic count sheet for Resident #1 revealed RN A signed out hydrocodone/acetaminophen 10/325mg on 7/6/23 at 12:00 am and at 6:00 am when RN A was not on duty. Record review of individual narcotic count sheet for Resident #4 revealed RN A signed out oxycodone 5mg on 7/5/23 two times while Resident #4 was in the hospital. These failures were determined to be past non-compliance due to the following evidence being implemented prior to the survey. Record review of urine drug screen for RN A dated 7/5/23 revealed a negative result. Record review of urine drug screen for RN A dated 7/6/23 revealed a positive result. Record review of in-service dated 7/7/23 titled Obtaining Drugs/Medications for residents upon admission with 11 employee signatures. Record review of in-service dated 7/7/23 titled Reminders: Drug Free Workplace Policy 1. Aware of handbook drug free workplace policy. 2. Review testing scenarios. 3. Drug free acknowledgements signed upon hire. 4. Refusal of requested drug screen is considered voluntary termination signed by 42 employees. Record review of in-service dated 7/10/23 titled Drug Diversion Prevention presented by the Admin with 14 employee signatures. Record review of termination form dated 7/10/23 revealed RN A had been terminated on 7/10/23. Record review of employee personnel file for RN A revealed a criminal background check had been completed on 4/10/23 prior to employment. Record review of QAPI dated 8/16/23 revealed action plan: Drug Diversion/ Misappropriation of Resident Property. 1. RN A suspended immediately with investigation done and RN A was terminated completed 7/10/23. 2. In servicing done with nursing staff regarding drug diversion and drug free workplace completed 7/10/23. 3. Implemented procedure for ongoing review of narcotic sheets completed 7/11/23 and ongoing. 4. Pharmacy consultant notified of situation completed 7/10/23. 5. Continue drug free workplace training upon hire, annually, and as needed ongoing. 6. Report any further issues or concerns to QAPI committee as needed ongoing. Record review of a facility policy titled Drug Diversion Guidelines dated 2/23/17 indicated .5. A drug count must be done at each shift change and should be done whenever the keys to the narcotic storage areas are exchanged from one staff to another. 10. Document administration of PRNs controlled substances on the MARs including dose, date, time, route, and effectiveness of medication. Reporting: 1. Drug diversions or potential drug diversions are reported immediately to Administrator, DON, Pharmacy, State Agency and Police for investigation . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675624 If continuation sheet Page 3 of 3