Health inspection·August 16, 2023

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 observation, interview, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and/or accurate for 1 of 1 resident (Resident #1) reviewed for clinical records. The facility did not maintain or complete progress notes or round sheets or Resident #1. This failure could place residents at risk for inaccurate documentation by staff. The findings were: Record review of clinical records for Resident #1 revealed a [AGE] year-old resident who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive disease that destroys memory and other important mental functions), generalized anxiety disorder (state of anxiousness), and insomnia (difficulty falling asleep). Record review of Resident #1's progress notes from an elopement observation made by the LVN A, dated 08/12/2023, at 8:30 PM, revealed the following: CNA's will do hourly checks on resident through the night to ensure safety. Record review of Resident #1's nursing notes, progress notes and observations, dated 08/12/2023 and 08/13/2023, revealed hourly rounds were not documented. Record review of Resident #1's Care plan, dated 08/01/2023, revealed the following: Elopement: I wander due to my diagnosis of age-related cognitive decline. I wear a roam alert bracelet. Goal: I will not elope from the center in the next 90 days. Record review of a Quarterly MDS, dated [DATE], revealed the following: Section C entitled BIMS revealed a score of 03, which indicated the resident was severely impaired. Section E entitled Behavior Assessment revealed: Wandering behavior not exhibited with the last 7 Page 1 of 2 455555 455555 08/16/2023 Avir at Graham 1224 Corvadura St Graham, TX 76450

F 0842 days. Level of Harm - Minimal harm or potential for actual harm Section P entitled Restrains and Alarms revealed: Wander and Elopement alarm was used daily. Residents Affected - Few Observation and Interview on 08/16/2023 at 8:30 AM revealed Resident #1 was lying in her bed asleep. The Regional RN revealed she had been aiding the facility, since the DON was out for a conference. She reported Resident #1 had been up the previous night and was now sleeping. She revealed an order for 1 on 1 with the resident due to an earlier attempted elopement and for the resident's safety, until they transferred her to another facility. She revealed they had identified an issue with the alarm system, and the front door and immediately they called the alarm company out to make sure it was functioning properly. She revealed they followed all the steps to ensure the resident was safe. Interview on 08/16/2023 at 1:15 PM with LVA A revealed she completed the progress note in the elopement observation which stated to check the resident every hour. She said she checked every hour, but she did not document that the resident was checked. She stated she should have scheduled the hourly checks. She failed to document due to becoming busy and forgetting after her shift was over. Interview with the Administrator on 08/16/2023 at 2:30 PM revealed her expectations were for documentation to be completed. She was completing an in-service with staff to correct the issue. Record review of the facility policy, provided on 08/16/2023, titled: Charting and Documentation, dated 07/2017, reflected the following: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record . 1. Documentation in the medical record may be electronic, manual or a combination. 2. The following information is to be documented in the resident medical record: a. Objective observations . e. Events, incidents or accidents involving the resident 4. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified Nursing Assistants may only make entries in the resident's medical chart as permitted by facility policy . 7. Documentation of procedures and treatments will include care-specific details 455555 Page 2 of 2