Health inspection·November 18, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interviews and record reviews, the facility failed to maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices that are complete, accurately documented, readily accessible, systematically organized and protected from unauthorized release for 3 (Resident #1, Resident #2, and Resident #3) of 4 residents reviewed for maintenance of clinical records. 1. The facility failed to ensure staff documented accurately after Resident #1 was found on the floor and sent out for evaluation on 10/12/25 and returned to the facility on [DATE].2. The facility failed to ensure staff updated the care plan for Resident #2 after she reported she had a fall on 09/15/25.3. The facility failed to ensure staff accurately documented a progress note after Resident #3 had an apparent unwitnessed fall on 10/13/25. These deficient practices could place residents at risk of injuries related to falls or not receiving necessary treatment.Findings included:1. Review of Resident #1's admission record, printed 10/15/25, reflected a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included unspecified intellectual disabilities, unsteadiness on feet, unspecified lack of coordination, dementia with agitation, and Alzheimer's disease with late onset. Review of Resident #1's MDS assessment dated [DATE] reflected he was rarely/never understood so a BIMS assessment was not completed. The MDS assessment reflected he needed set up assistance for transfers and ambulation and had no falls since the prior MDS assessment. Review of Resident #1's comprehensive care plan initiated 08/07/25, reflected in part, Focus: I am at risk for falls related to unsteady gait, history of falls, muscle weakness, cognitive impairment. Goal: I will remain free from injury due to falls. Interventions/Tasks: I will be given non-skid socks or footwear to help me move safely. I will be assisted with walking, transfers, or toileting as needed, based on my current ability. Review of the incident log from 09/01/25 through 10/14/25, reflected Resident #1 had an unwitnessed fall on 10/12/25 at 8:30 PM. Review of Resident #1's progress note dated 10/13/25 at 5:48 AM., and written by LVN A, reflected EMS was notified and Resident #1 was sent to the acute hospital after being found on the floor. Review of Resident #1's progress notes from 09/14/25 to 10/15/25 reflected there were no notes to address: The date and time the resident was found on the floor and sent out to the hospital or the date and time the resident had returned to the facility. During an interview on 10/14/25 at 2:25 PM., LVN B stated Resident #1 had gone out to the hospital sometime on the night shift on 10/12/14. She stated when she was coming in for her shift on the morning of 10/13/25, Resident #1 was just returning to the facility. LVN B stated if there was an unwitnessed fall, they were expected to get vital signs, complete a head-to-toe assessment, write a progress note and incident report, and notify the NP/MD, RP, and DON. She stated thorough documentation was important to ensure the residents received the proper care. During an interview on 10/15/25 at 10:57 AM, the VPCO stated the DON had told her Resident #1 had been sent out to the hospital on [DATE] because of Page 1 of 3 675132 675132 11/18/2025 Bremond Nursing and Rehabilitation Center 211 N Main Bremond, TX 76629

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a fall. She stated with any fall; she expected the event to be reported. That report triggered the required assessments. She expected the DON to complete an assessment and to reassess the resident before closing out the event at 72 hours as some bruises took time to develop. She stated if the documentation was missing or not accurate, there was no way to assess the outcome, and the facility may have missed something. During an interview on 10/15/25 at 11:42 AM, the DON stated she expected documentation to be accurate and timely. She expected after a fall the nurse completed a fall assessment, a progress note, an incident report, notification of the NP/MD, RP, and DON. She stated she and the ADON were responsible for monitoring the documentation and train/in-service staff, but since the ADON was out, she was responsible. The DON stated the ADON was also the MDS nurse who was responsible for care plans. She stated while the ADON was out, she was responsible for ensuring care plans were updated. During an interview on 10/15/25 at 12:18 PM, the ADM stated it was important that documentation was thorough and timely. She expected staff to take care of the resident first then complete the documentation. She stated it was her expectation that the documentation painted a picture of the resident's status so anyone would know what happened. She expected all documentation was completed before the staff left at the end of their shift. The ADM stated the new ADON was responsible for monitoring documentation, but she was out on leave, so the monitoring was done by the DON. During an observation and attempted interview on 10/15/25 at 1:28 PM, Resident #1 was sitting in a wheelchair in the dayroom. His posture was relaxed, no indicators of pain or distress observed. He made eye contact and smiled. He responded to questions with a giggle but did not respond verbally. A telephone interview with LVN A was attempted on 10/15/25 at 10:43 AM. A telephone interview with LVN A was attempted on 10/15/25 at 2:03 PM. No return call was received prior to the exit. 2.Review of Resident #2's admission record, printed 10/15/25, reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), abnormalities of gait and mobility, muscle weakness, and repeated falls. Review of Resident #2's quarterly admission assessment, dated 09/08/25, reflected a BIMS score of 12 which indicated moderately impaired cognition. The assessment reflected Resident #2 needed set up assistance for transfers and ambulation. The assessment reflected no falls since the prior assessment. Review of Resident #2's comprehensive care plan, initiated 08/11/25, reflected in part, Focus: I am at risk for falls related to unsteady gait, history of falls, muscle weakness. Goal: I will remain free from injury. Interventions/Tasks: I will be reminded to use my call light. Staff will ensure my bed is in the lowest position, wheels are locked, and the call light is always within reach. My care plan will be updated after any fall or change in condition. Further review revealed the fall care plan did not reflect any revisions after the 09/15/25 fall. Review of Resident #2's progress note dated 09/15/25 at 5:05 AM, and written by LVN C, reflected in part, Resident reported that she fell. she stated she hit her left arm. Upon assessment, a laceration was noted. When asked if she would like to be sent out for further evaluation, resident declined. Wound cleansed. Review of the incident log from 09/01/25 through 10/14/25, reflected Resident #2 had an unwitnessed fall on 09/14/25 at 8:46 PM. Review of Resident #2's Fall Risk Evaluation, dated 09/15/25, reflected that she was at high risk of falls. During an interview on 10/15/25 at 1:20 PM, Resident #2 stated she had a fall at the facility but did not remember when it happened. She stated nothing was hurt besides her pride and she declined to be sent out to the hospital. She stated staff were attentive and checked on her frequently. 3.Review of Resident #3's admission record, printed 10/15/25, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis list reflected schizoaffective disorder, bipolar type. Review of Resident #3's medical record reflected her MDS assessment was not yet due nor completed. Review of Resident #3's baseline care plan, initiated 675132 Page 2 of 3 675132 11/18/2025 Bremond Nursing and Rehabilitation Center 211 N Main Bremond, TX 76629

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10/13/25, reflected in part, Focus: I am at risk for falls related to unsteady gait, history of falls, muscle weakness, cognitive impairment. Goal: I will remain free from injury. Interventions/Tasks: I will be given non-skid socks or footwear to help me move safely. I will be reminded to use my call light. Staff will ensure my bed is in the lowest position. Review of the incident log from 09/01/25 through 10/14/25, reflected Resident #3 had an unwitnessed fall on 10/13/25 at 7:30 PM. Review of Resident #3's progress notes from 10/13/25 through 10/15/25 at 1:03 PM, reflected no progress note regarding a fall. Review of Resident #3's Fall Risk Evaluation dated 10/13/25 at 11:28 PM, reflected a score of 14 which indicated she was at risk for falls. During an interview on 10/15/25 at 11:42 AM, the DON stated she witnessed Resident #3 on the floor on the evening of 10/13/25. She stated she treated it as an unwitnessed fall and initiated the incident report and assessments. She stated she did not document a progress note but should have. During an observation and interview on 10/25/25 at 1:45 PM, Resident #3 was observed sitting up in a wheelchair in her room dressed in clean clothes. No bruises or injuries were observed on her exposed skin. Resident #3 stated she felt good because she just had a shower. When asked if she had a fall at the facility, she stated, About 25 times. She repeated that she had about 25 falls. She denied pain, and she denied any injuries. She stated she felt safe at the facility and wanted to stay there forever. Review of the facility's Incidents and Accidents policy, reviewed/revised 04/11/25, reflected in part, It is the policy of this facility for staff to utilize (Title) to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve a resident. Compliance Guidelines: 12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. 13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained for follow-up interventions. Review of the facility's Fall Prevention Program policy, Reviewed/Revised 10/14/25, reflected in part, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Compliance Guidelines: When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. 675132 Page 3 of 3