Inspection·May 5, 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 medical records, in accordance with accepted professional standards and practices were complete, accurately documented, readily accessible and systematically organized for 1 of 12 residents (Resident #20) reviewed for accuracy of medical records, in that: The facility failed to obtain a physician's order for Resident #20's code status. This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors in care and treatment. The findings were: Record review of Resident #20's face sheet, dated 5/5/23 revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] and 3/9/23 with diagnoses that included orthopedic aftercare following surgical amputation, diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), heart failure and acquired absence of right leg above the knee. Record review of Resident #20's most recent Significant Change MDS, dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and required two-person physical assist with bed mobility and transfers. Record review of Resident #20's comprehensive care plan, revision date 4/23/23 revealed the resident was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) with interventions that included to review advanced directive options quarterly and as needed and obtain a copy of full code status physician's order. Record review of Resident #20's Order Summary Report, dated 5/3/23 revealed there were no physician's orders for code status. During an observation and interview on 5/4/23 at 1:44 p.m., LVN A revealed a resident's code status could be determined by looking in the resident's electronic record under the resident profile which included a picture of the resident, the code status, admission information and date of birth . LVN A revealed she believed Resident #20 had a DNR code status. LVN A logged into Resident #20's profile in the electronic record and revealed, the subheading under code status was blank. LVN A revealed a physician's order for code status was required but did not know the reason why. LVN A revealed she (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 675373 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 675373 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Springs Rehabilitation and Healthcare C 506 S 7th St Carrizo Springs, TX 78834 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)