Health inspection·March 21, 2024

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #1's progress note, dated 03/20/24 at 12:26 pm, revealed Resident #1 was receiving oxygen at 2 lpm vis nasal cannula. In an interview on 03/21/24 at 10:00 am, the DON said it was ultimately her responsibility to make sure resident's orders were correct upon admission. She said the DON and ADON were checking to make sure resident's physician orders were correct but didn't know how it got missed. The DON stated I failed to get orders for oxygen for Resident #1. She said a potential negative outcome would be residents would not get the treatment they needed. Resident #2 Record review of Resident #2's face sheet, dated 03/20/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of dementia (the general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities) and shortness of breath. Resident #2 was discharged from the facility on 03/17/24. Record review of Resident #2's Physician Order Summary, dated 03/20/24 revealed Resident #2 did not have an order for Oxygen PRN. Record review of Resident #2's progress note, dated 07/05/23 at 10:01 am, revealed Resident #2 was placed on Oxygen 3 lpm via nasal cannula due to her oxygen levels being below 90%. Record review of the Nurse Practitioner progress note, dated 07/05/23 at 12:52 pm, revealed Nurse Practitioner A placed Resident #2 on oxygen for shortness of breath. Record review of Resident #2's progress note, dated 07/10/23 at 5:50 pm, revealed the resident was receiving Oxygen 2 lpm via nasal cannula. Record review of Resident #2's progress note, dated 08/25/23 at 11:53 am, revealed Resident #2 was placed on Oxygen 2 lpm via nasal cannula due to shortness of breath. Record review of Resident #2's progress note, dated 03/17/24 at 1:15 pm, revealed Resident #2 was placed on Oxygen at 3 lpm for shortness of breath. In an interview on 03/20/24 at 12:45 pm, LVN B said Resident #2 had an oxygen concentrator in her room and Resident #2 would have shortness of breath from time and time and she would be placed on Oxygen 2 lpm PRN. LVN A said she thought Resident #2 had a physician order for Oxygen PRN. In an interview on 03/21/24 at 2:30 pm, the Clinical Regional Nurse Consultant said when Resident #2 was placed on oxygen on 07/05/23, that was when Resident #2 should have had a Physicians Order for Oxygen to be administered PRN. She said the nurse at the time failed to get an order from the doctor. She said there was no order in Resident #2 Physicians Orders for Oxygen PRN. In an interview on 03/21/24 at 3:07 pm, Nurse Practitioner A said Resident #2 only required Oxygen PRN. She remembered an incident a while back in which Resident #2 received Oxygen PRN but did not recall whether if an order was written for Resident #2 to receive Oxygen PRN. Record review of the facility policy Following Physician Orders, dated as implemented 09/28/21, revealed the following [in part]: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676034 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 676034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brady West Rehab & Nursing 2201 Menard Hwy Brady, TX 76825 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 0695 Policy: This policy provides guidance on receiving and following physician orders. Level of Harm - Minimal harm or potential for actual harm Policy Explanation and Compliance Guidelines: 2. For consulting physician/practitioner orders received via fax, the nurse in a timely manner will: Residents Affected - Some a. Document the order by entering the order and the time, date, and signature on the physician order. b. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. 3. For consulting physician/practitioner orders received via telephone, the nurse will: a. Document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order. b. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. c. Carry out and implement the physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676034 If continuation sheet Page 3 of 3