Health inspection·March 4, 2024

F 0551 Give the resident's representative the ability to exercise the resident's rights. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to allow the resident representative the right to exercise the resident's rights to the extent those rights were delegated to the representative for 1 of 1 resident (Resident #1) reviewed for resident rights. Residents Affected - Few The facility failed to provide Resident #1's medical records, when Resident #1's POA requested them on 02/07/24. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions. The findings included: A record review of Resident #1's electronic Facesheet, dated 02/21/24, indicated Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses which included pressure ulcer of sacral region, other chronic pain, non-pressure chronic ulcer, arthritis, muscle weakness, lack of coordination, and repeated falls. A record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 10, which indicated his cognition was moderately impaired. A record review of Resident #1's Care Plan, revised 12/04/23, reflected Resident #1 was in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidenced by an inability to provide selfcare and discharge planning is not needed. Either the family or the resident has requested that questions regarding return to the community only be asked on comprehensive assessments. The goals for this concern included Resident and families wishes will be honored through next review date and the interventions included Observe for change in conditions that may affect long-term care goals and notify the physician and responsible party as needed. In an interview on 02/23/24 at 2:02 PM, Resident #1's POA stated on 02/07/23 she was in the BOM's office and requested Resident #1's medical records. The POA stated the BOM told her she would need to request the records from the MRC. She stated the MRC passed by the BOM office and the BOM told the MRC that she had requested the records. The POA stated the MRC said ok and rolled her eyes. She stated she went to speak to the ADMN about the incident and the ADMN told her it was a process to get the records and could take 3 days. The POA stated the ADMN told her once the request was made, she had to send it to corporate and wait for approval before they could provide the medial records. The POA stated she still had not received the records. She stated she was the POA for Resident #1 and there was no reason she should not have received the records. The POA stated she was at the facility 2-3 Page 1 of 2 455996 455996 03/04/2024 The Renaissance at Kessler Park 2428 Bahama Dr Dallas, TX 75211

F 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few days ago and tried to speak to the ADMN to follow up about the records, but she would not speak to her. The POA stated as of today, she still had not received the records. In an interview on 02/23/24 at 3:05 PM, the ADMN stated she did not speak to Resident #1's POA about requesting his medical records. The ADMN stated Resident #1's FM was entitled to receive his medical records because she was his POA. The ADMN stated the facility's process for requesting medical records included, the MRC completing a request form, the form would be forwarded to their corporate office, once the corporate office approved the form, she would notify the MRC, who would provide the records. The ADM stated she never received a request form from the MRC and the MRC was currently suspended due to another issue. When the ADMN was asked about Resident #1's POA reporting the incident with MRC in the BOM's office, she stated she did recall speaking to her about this. The ADMN called the BOM into her office. The BOM stated she did recall Resident #1's POA requesting Resident #1's medical records on 02/07/24. The BOM stated she told the POA that she did not handle medical records, but she notified the MRC. The BOM stated she was not sure what happened after that. The BOM stated she did speak to the ADMN about the medical records because the POA was at the facility she believed Tuesday (02/20/24) or Wednesday (02/21/24) and was upset that she still had not received the medical records and could not speak to the ADMN. The ADMN stated she did not recall that conversation with the BOM. In an interview on 02/23/24 at 3:21 PM, the MRC stated did recall Resident #1's POA requesting his medical records. She stated the BOM notified her that the POA was requesting the records. The MRC stated when she looked in PCC she did not see that Resident #1's FM was the POA. The MRC stated she contacted Resident #1's FM and the FM said that was incorrect and the ADMN had notarized the document for her being the POA. The MRC stated she asked the ADMN about it, and the ADMN verified Resident #1's FM was the POA. The MRC stated by that time it was at the end of the day and she left the facility. She stated she forgot to follow up the next day to fill out the form. The MRC stated she messed up and just forgot. She stated it was the POA's right to receive medical records. In a follow up interview on 02/23/24 at 4:15 PM, the ADMN stated Resident #1's POA had requested the records and the facility did not provide them. She stated it was the POA's right to receive the medical records and she would get them sent to the POA. A record review of the facility's policy titled Resident Rights, dated 02/23/16, reflected .b. In the case of a resident who has not been adjudged incompetent by the State court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by State law . d. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative . 6. Information and communication . a. The resident has the right to access personal and medical records pertaining to him or herself. 455996 Page 2 of 2