Health inspection·February 28, 2025

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 interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 2 (Resident #1 and Resident #2) of 20 residents reviewed for clinical records, in that: 1. Resident #1's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident. 2. Resident #2's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident. These deficient practices could result in in errors in care and treatment. The findings were: 1. Record review of Resident #1's facesheet, dated 02/27/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, Cerebral Infarction and Vascular Dementia Unspecified Severity Without Behavioral Disturbance. Record review of Resident #1's annual MDS, dated [DATE], revealed a BIMS score of 07 which indicated severe cognitive impairment. Record review of Resident #1's care plan, dated 02/27/2025, revealed, [Resident #1] has a behavioral problem where she has delusions [related to] dementia and a cerebral infarction. She says statements that after investigation have been found to be not true . The resident is/has potential to be physically aggressive to staff and others. Record review of Resident #1's psychiatric provider after visit note, dated 02/11/2025, revealed, Active Medical Problems .delusions . neuropathy .Assessment and Plan: Dementia with Behaviors. Further review of Resident #1's facesheet, dated 02/27/2025, revealed the diagnoses of delusions, neuropathy, and dementia with behaviors were not noted. 2. Record review of Resident #2's facesheet, dated 02/27/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Other Specified Interstitial Pulmonary Diseases, Anemia, and Insomnia. Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 0 which Page 1 of 2 455724 455724 02/28/2025 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0842 indicated severe cognitive impairment. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's care plan, dated 02/27/2025, revealed, [Resident #2] has little or no activity involvement [related to] disinterest, resident wishes not to participate . Residents Affected - Few Record review of Resident #2's psychiatric provider after visit note, dated 02/11/2025, revealed, Active Medical Problems .Major Depressive Disorder . Record review of Resident #2's Order Summary Report, dated 02/27/2025, revealed, Amitriptyline HCl Oral Tablet 25 [milligrams] (Amitriptyline HCl) Give 1 tablet by mouth at bedtime every 2 day(s) for Depression. Further review of Resident #2's facesheet, dated 02/27/2025, revealed the diagnosis of Major Depressive Disorder was not noted. During an interview with the DON on 02/28/2025 at 9:30 a.m., the DON confirmed Resident #1's diagnoses of delusions, neuropathy, and dementia with behaviors were not noted on the resident's face sheet and should have been. The DON additionally confirmed that Resident #2's diagnosis of Major Depressive Disorder was not noted on the resident's face sheet and should have been. The DON stated the facility had recently changed from one electronic health record provider to another and that the oversight was likely due to the change. The DON stated nursing staff were responsible to ensure accuracy of records, and nurse management were responsible for oversight of nursing staff. The DON confirmed that inaccuracy of the residents' clinical records could result in errors in care and treatment. Record review of the facility policy, Electronic Medical Records, dated 2001, revealed, Electronic medical records may be used in lieu of paper records when approved by the administrator. 455724 Page 2 of 2