Inspection·April 4, 2024

F 0697 for chronic pain. Level of Harm - Minimal harm or potential for actual harm Review of the March 2024 MAR for Resident #1 reflected the 09:00 AM and 09:00 PM administrations were marked 9, indicated on the MAR key by 9=Other / See Progress Notes. These administrations were signed by MA B. Residents Affected - Few Review of the progress notes for Resident #1 from 03/29/24 to 03/31/24 reflected the following notes: 03/29/24 01:02 PM Note Text: (np) called and updated to reorder norco 10-325mg to pharmacy. 03/31/24 03:12 AM Acetaminophen Oral Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain/fever 2 tabs to = 650mg, to not exceed more than 3 grams from all sources in a 24hr period. 03/31/24 05:56 AM Acetaminophen Oral Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain/fever 2 tabs to = 650mg, to not exceed more than 3 grams from all sources in a 24hr period PRN Administration was: Effective Follow-up Pain Scale was: 0. 03/31/24 10:54 AM Acetaminophen Oral Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain/fever 2 tabs to = 650mg, to not exceed more than 3 grams from all sources in a 24hr period. 03/31/24 03:09 PM Acetaminophen Oral Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain/fever 2 tabs to = 650mg, to not exceed more than 3 grams from all sources in a 24hr period PRN Administration was: Effective Follow-up Pain Scale was: 0. 03/31/24 08:44 PM HYDROcodone-Acetaminophen Oral Tablet 10-325 MG Give 2 tablet by mouth two times a day for chronic pain. Pending delivery from the pharmacy. Review of administrations from the facility emergency kit reflected Resident #1 was given 2 tablets of hydrocodone at 09:40 PM on 03/28/24 and that LVN A signed out the dose. There were no other administrations recorded for her after that. Review of pain assessments for Resident #1 from 03/29/24 to 03/31/24 reflected she was assessed three times per day (day shift, evening shift, and overnight shift) for pain and reported a pain level of 0 each time, indicating she was in no pain. The dayshift and evening shift assessments for 03/30/24 and 03/31/24 were conducted by LVN A. Observation and interview on 04/04/24 at 02:06 PM revealed Resident #1 laying in bed under blankets. She was calm and stated she was comfortable. She stated she had experienced an issue with her pain medications the previous weekend from Friday 03/29/24 to 03/31/24. She stated her usual hydrocodone was white, and on Thursday night 03/28/24, she received a dose that was blue. Resident #1 stated she thought it was unusual, but it did not concern her. She stated she looked up the number printed on the pills that evening and saw they were hydrocodone, so she took them. She stated the following morning, 03/29/24, she should have received another dose, but MA B told her the pills had not arrived from the pharmacy. She stated she went through the whole weekend with MA B telling her the pills (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 2 of 4 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were not available. She stated she started to feel poorly; her legs were irritated, and she was sweaty. She stated she was always in pain due to her rheumatoid arthritis, and she had been on the hydrocodone for 13 years. She stated the medications did not do a lot for her pain, but she was used to having them. She stated she felt strange, so she did not know if she was going through withdrawal. She stated the nurse came in and checked her vital signs, which were fine. Resident #1 stated she did not say anything to the nurse about the missing medication, because Resident #1 figured if MA B knew, the nurse must have known. Resident #1 stated all day Sunday she was very hot and sweaty, and finally she asked LVN A what was going on with her hydrocodone. Resident #1 stated LVN A then reached out and took care of the issue, and the hydrocodone came in that night. Resident #1 stated she received a dose around 10:00 PM on Sunday night 03/31/24. An interview was attempted on 04/04/24 at 02:23 PM with MA B. A voicemail was left but no return contact occurred as of 04/11/24. During an interview on 04/04/24 at 03:40 PM, LVN A stated she conducted several pain assessments for Resident #1 from 03/29/24 to 03/31/24, and Resident #1 never communicated that she was in pain. LVN A stated she did not see any nonverbal signs of pain during that time: no tremors, sweating, nausea, or anything that would indicate distress. LVN A stated LVN A had called the NP on the night of 03/28/24 and requested the hydrocodone be refilled. LVN A stated she also pulled a hydrocodone from the emergency kit that evening for Resident #1. LVN A stated she did not work on Friday 03/29/24. LVN A stated when she returned on 03/30/24, she assumed the medication had arrived, because Resident #1 did not complain, and the medication aide did not report any unavailable medications to her. LVN A stated it was not until late Sunday morning that Resident #1 told LVN A she had a bad night the night before and told her she had not received her hydrocodone since the previous Thursday night 03/28/24 that LVN A realized the medication was still unavailable. LVN A stated she called the pharmacy and learned they had not received the request from the weekday NP yet. LVN A stated she then called the on call NP who sent a triplicate request form to the pharmacy, and the medication was delivered later that night. LVN A stated the administration record reflected that Resident #1 was administered Tylenol on 03/30/24 and 03/31/24. LVN A stated she did not know why the nurse on duty 03/30/24 had not administered any doses of the medication from the emergency kit. LVN A stated she did not, because she did not know the medication was unavailable until mid-day 03/31/24. During an interview on 04/04/24 at 04:14 PM, the ADON stated the IDt had been aware Resident #1's hydrocodone had not come in during their morning meeting on 03/29/24, and she had asked LVN C to follow up with the pharmacy and the NP to find out what was going on. The ADON stated she did not find out if LVN C followed up or what the result was, and the ADON was just now finding out that Resident #1 went without her hydrocodone all weekend. The ADON stated they ensured residents had the medications they needed for pain management, because they had and emergency kit. The ADON stated they pulled reports that let them know if something was missing, but because it was the weekend, there was no one present to pull the report. She stated they had no process during the weekend to oversee if medications were unavailable and relied on the staff to report verbally so they could get the medications that were needed. She stated she and the DON were both responsible for ensuring the residents had their scheduled medications available. The ADON stated without available hydrocodone, a resident could go with uncontrolled pain. During an interview on 04/04/24 04:45 PM, the DON stated the first point of contact/responsible person for ensuring residents had their pain medications available was the charge nurse. The DON stated the managers reviewed a report each weekday morning to address any issues or missing medications, but on weekends, it was up to the charge nurses on duty to monitor that system. She stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 3 of 4 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ensured the staff were compliant with their system by training them to communicate when something is wrong. The DON stated the staff knew they had to give the medications and follow orders, and if the medications were not available, they knew they had to communicate directly for each missed administration. She stated it was also their policy to reorder medications well ahead of time: the aides needed to let the nurses know to reorder, and the nurses needed to do the reordering. The DON stated Resident #1's hydrocodone was scheduled, and there must have been a communication lapse from MA B to the nurses on duty those days. The DON stated a potential negative outcome of the failure was residents would be uncomfortable and would not feel very comfortable. Review of in-services from January 2024 to March 2024 reflected the following: Medication Administration 03/07/24 Medication Administration 03/14/24 Medication Administration 03/19/24 Medication Administration 03/26/24 Review of the facility policy dated 08/15/22 and titled Pain Management reflected the following: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility will utilize a systematic approach for recognition, assessment, treatment, and monitoring of pain. Review of facility policy dated 10/24/22 and titled Medication Administration reflected the following: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of facility policy dated 10/01/19 and titled Ordering and Receiving Medications from Pharmacy reflected the following: It will be the responsibility of the facility to re-order the medication to avoid any lapse in therapy. And Controlled substances are re-ordered a five-day supply remains to allow for transmittal of the required written prescription to the pharmacist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 4 of 4