Inspection·October 5, 2023

F 0641 Ensure each resident receives an accurate assessment. 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 accurately assess each resident's status for 1 of 3 Residents (Resident #1) reviewed for assessment accuracy in that: Residents Affected - Few Resident #1's Annual MDS dated [DATE] did not have Section N (under Gradual Dose Reduction) coded correctly to reflect that the resident has received a Gradual Dose Reduction and that the medication is not contraindicated. This failure could place residents at risk of not receiving the proper care and services due to inaccurate records. Finding included: Record review of Resident #1's Face Sheet, dated 05/05/2023, revealed a [AGE] year-old male, re-admitted to the facility on [DATE] with admitting diagnosis of bipolar disorder (mood swings that range form from depressive lows to manic highs) and major depressive disorder (persistent depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of the Annual MDS assessment, dated 03/28/2023, revealed the following: Section C- BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Section I- active diagnosis of anxiety (state of anxiousness), depression (feeling of sadness), bipolar disorder (mood swings that range from depressive lows to manic highs), major depressive disorder (persistent depressed mood or loss of interest in activities, causing significant impairment in daily life) and schizophrenia (relapsing episodes of psychosis). Section N- Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent- Yes. Has a gradual dose had not been attempted- No. Has a physician documented gradual dose reduction as contraindicated- No. Record review of Resident 1's Physician Orders dated 02/24/2023 revealed orders for Risperdal (antipsychotic) 2 mg tablet: twice daily. Record review of Resident #1's Physician notes dated 02/24/2023 revealed that a GDR was not indicated (the medication was gradually reduced) at this time, as patient is stable on current dose. Record review of Resident #1's Care Plan, last revised on 09/12/2023, revealed care plans for: uses psychotropic medications; antidepressant and antipsychotic related to bipolar disorder, schizoaffective disorder, depression, and anxiety. The resident will remain free of drug related complications, (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 3 Event ID: 675554 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 675554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Nocona 306 Carolyn Rd Nocona, TX 76255 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)