Health inspection·January 2, 2026

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few blue foam(antibacterial wound dressing), secure with kerlix (gauze bandage) and ace wrap and to change twice weekly and prn and indicated every 72 hours for wound care. Review reflected wound care was performed on 11/25/2025. Review reflected Resident #1 refused wound care on 11/28/2025 and not performed. Review of wound assessment report by wound care NP dated 11/25/2025 reflected treatment as three times per week and PRN, cleanse with wound cleanser, xeroform(sterile mesh gauze dressing with treatment to fight bacteria), with ABD (abdominal pad) and kerlix as dressings for bilateral extremities. Review reflected exudate amount (how much fluid saturates the dressing) as heavy. Review of Resident #1's December 2025 TAR dated 11/24/2025 and discontinued 12/04/2025 reflected bilateral lower extremity and clean wounds with saline and gauze, remove crusts, dress wounds with hydrofera blue foam, secure with kerlix and ace wrap and to change twice weekly and prn and indicated every 72 hours for wound care. Review reflected Resident #1 refused wound care on 12/02/2025. Review reflected new order dated 12/04/2025 and discontinued 12/28/2025 for bilateral lower extremity, to clean wounds with saline and gauze, remove crusts, dress wounds with xeroform, secure with kerlix and ace wrap, change twice weekly and PRN every day shift every Tuesday and Friday. Review reflected wound care was performed on 12/05/2025 and 12/09/2025. Wound care was not performed on 12/04/2025 or 12/06/2025. Review reflected wound care was not provided on 12/10/2025, 12/11/2025 or 12/12/2025. Review of November 2025 and December 2025 MAR/TAR reflected no PRN wound care was completed. Review of Resident #1 progress notes reflected no PRN wound care was completed on 12/2/2025 or 12/11/2025. Review of wound assessment report by wound care NP dated 12/2/2025 reflected treatment as three times per week and PRN, cleanse with wound cleanser, xeroform, with ABD (abdominal pad) and kerlix as dressings for bilateral extremities. Review reflected exudate amount as heavy. Review of wound assessment report by wound care NP dated 12/09/2025 reflected treatment as daily and PRN, cleanse wound with wound cleanser, calcium alginate (natural gelatinous substance derived from brown seaweed) with ABD and kerlix as dressings for bilateral extremities. Review reflected exudate amount as heavy. Review of photo of Resident #1's right ankle with date of 12/2/2025 and timestamp of 2:50 PM, revealed dark spots on outside of bandage. Review of photo of Resident #1's right foot with date of 12/11/2025 and time stamp of 7:32 PM, revealed several dark black/brown spots on outside of bandage. During an interview on 12/30/2025 at 2:16 PM, FM stated the facility was supposed to keep Resident #1's legs clean so they could heal. FM stated that the wrapping around Resident #1's legs and feet had blood on them and felt that the same bandages were applied after wound care. FM stated that one nurse put xeroform on Resident #1's legs and felt that was against doctor's orders. During an interview on 12/31/2025 at 1:41 PM, LVN A stated that Resident #1 was not always compliant with dressing changes. LVN A stated that he refused wound care 2 or three times. LVN A described the wounds on Resident #1's legs as the same throughout his stay. LVN A stated that there was drainage and there was no odor or warmth. LVN A stated that at first the wound care NP had xeroform as part of the treatment but Resident #1's FM stated they could not use xeroform and the wound care nurse changed the order to utilize calcium alginate. LVN A stated Resident #1's FM felt xeroform would macerate it. LVN A stated macerated meant to turn the skin really soft and she did not observe this when she used xeroform for Resident #1's wound care. LVN A stated that Resident #1 received wound care twice a week per order from the wound care NP. LVN A stated the orders Resident #1 came with from the hospital were for every 72 hours. LVN A stated the wound care NP decided to change from every 72 hours to twice a week because hospital orders were clarified. LVN A stated she observed a small circle on Resident #1's dressing and denied any color was observed. LVN A stated Resident #1's wounds were open and had drainage. LVN A stated the drainage was clear and had some blood mixed with it. LVN A stated calcium alginate was a dressing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 2 of 8 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pad. LVN A stated the wound would be cleaned, then calcium alginate would go on top. LVN A stated she then put ABD pads and an ace wrap. LVN A stated ABD was a dressing to help with drainage and then it would be wrapped. LVN A stated sometimes Resident #1 would have drainage seeping through his dressing but not very much. LVN A stated she would find the soiled dressing and it was usually when she was going to do the wound care. LVN A stated she did not recall when she saw the soiled dressing. LVN A stated if residents had drainage seeping through their dressing, they could get a dressing changed sooner than their scheduled wound care. LVN A stated she would have expected report from the CNA or charge nurse to report any soiled dressing to her. LVN A stated potential harm of soiled dressing that went unchanged was an infection. LVN A viewed the picture dated 12/11/2025 and stated she did see soiled dressing similar to the picture at least once or twice. LVN A stated that the wound care NP did not express any concerns about the soiled dressings and that she was usually with the wound care NP when LVN A saw the soiled dressing. LVN A stated that after the care plan meeting with Resident #1's FM she informed the wound care NP that the FM wanted the order to be changed to calcium alginate. LVN A stated that the meeting was held maybe the 2nd or 3rd week after Resident #1 was admitted . During an interview on 12/31/2025 at 2:00 PM, RN B stated that she observed drainage that seeped through Resident #1's dressing. RN B stated when she saw it, she thought it looked like blood. RN B stated she thought she reported it to LVN A and put a note in PCC (point click care, electronic health record). RN B stated Resident #1's FM asked why the wound was always like this and meant that the dressing was soiled. RN B stated she told Resident #1's FM she would tell LVN A. RN B stated it was maybe one drop on Resident #1's shin area. RN B stated Resident #1's dressing was not supposed to be changed each time there was soiled dressing on his wounds. RN B stated if she saw a lot of drainage she would report it to LVN A, but she never saw a lot of drainage through Resident #1's dressing. RN B stated it was important to report a soiled dressing because it could have been considered neglect and could potentially cause an infection. RN B stated if it was a lot of drainage she would have called LVN A and assessed if the dressing had just been changed or soaked through or needed to be changed. RN B observed the picture dated 12/11/2025 and denied that she ever observed Resident #1's dressing soiled as in the picture. During an interview on 12/31/2025 at 2:48 PM, NP stated she saw Resident #1 on 12/12/2025 and observed blood drainage on his dressing and stated Resident #1 was due for a dressing change. NP stated she asked LVN A to follow up and get the dressing changed. NP stated some wounds were going to drain and some dressing should not be changed too much to avoid disturbing the healing process. She stated she did not observe any odor or warmth to Resident #1's leg. NP stated she would default questions about wound care to the wound care NP. During an interview on 1/2/2026 at 8:57 AM, wound care NP stated she saw Resident #1 two or three times. Wound care NP stated Resident #1 had severe wounds on both of his legs from to the top of his feet. Wound care NP stated that when Resident #1 first arrived there were ABD pads wrapped in gauze. Wound care NP stated she believed the facility got ABD pads and put xeroform on Resident #1's wounds. Wound care NP stated that Resident #1's FM wanted his treatment switched to utilize calcium alginate so it was switched. Wound care NP stated from when she first saw Resident #1 to the last time his wounds appeared the same each visit. Wound care NP stated she did not recall any signs of infection. Wound care NP stated she did not recall Resident #1's dressings being soiled. Wound care NP stated that it would not be uncommon to have draining wounds with soiling on the outer bandage. Wound care NP stated if the outer bandage was soiled it should have been removed and reapplied. Wound care NP stated this included the ace bandage. Wound care NP stated she would not have changed wound care from three times a week to two times a week. Wound care NP stated that if anything she would have increased wound care from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 3 of 8 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few three times a week to daily. Wound care NP stated that if they used xeroform three times a week dressing change is recommended and if they used calcium alginate then wound care should have been done daily. Wound care NP stated that hydrofera blue foam is very different from xeroform. Wound care NP stated hydrofera blue foam is thicker and antimicrobial and xeroform would be changed three times a week because it helped dry out a wound. Wound care NP stated it would not have been suggested to only change dressings twice a week if xeroform was used. Wound care NP stated it was hard to answer if it would have made a difference that hydrofera blue foam was used versus xeroform. Wound care NP stated she expected the facility to follow hospital discharge orders and then evaluate with the wound care team if anything needed to be changed. Wound care NP stated she did not see hydrofera blue foam used on Resident #1's wounds. During an interview on 01/02/2026 at 9:22 AM, LVN A stated when a resident admitted from the hospital she tried to see the wound care discharge orders but did not see them all. LVN A stated the charge nurse put orders in PCC and she will go in and see that it matches hospital discharge orders. LVN A stated that she reviewed the wound care report and the notes were sent to her. LVN A stated that the treatment on the wound care report should be the same as the order in PCC. LVN A stated that change twice weekly prn and every 72 hours did not make sense as an order because twice weekly and every 72 hours were different. LVN A stated if something was changed twice a week versus three times a week it could have made a difference in wound healing and could have slowed wound healing. LVN A stated if xeroform was being used it should be changed three times a week, but it was dependent on what the wound care NP stated. LVN A stated the order was changed to twice a week because she and the wound care NP had discussed it in Resident #1's room and LVN A stated she guessed she missed the order being updated. LVN A stated looking back three times a week wound care would have been more appropriate. LVN A stated she tired to review the wound assessment report the day it was emailed to her. LVN A stated she sometimes received the reports the same day or following day. LVN A stated that there were no residents who received wound care twice a week. LVN A stated when she viewed the wound care report she tried to go into PCC to ensure the order matched. During a subsequent interview on 1/2/2026 at 9:41 AM, wound care NP stated she did not recall changing wound care to only twice a week and she would not have because of Resident #1's drainage. Wound care NP stated it would have been at least three times a week at minimum when using xeroform but when it changed to calcium alginate it would have been daily and as needed. Wound care NP stated when she changed an order she talked about it with LVN A and she sent a report from wound rounds the same day to show recommendations. Wound care NP stated she expected the facility to follow recommendations and if they had questions they could reach out. Wound care NP stated no residents received wound care twice a week and the standard was three times a week. During an interview on 01/02/2026 at 10:09 AM, LVN E stated that she worked with Resident #1. LVN E stated that LVN A provided wound care for Resident #1. LVN E stated that Resident #1's wound did drain and there were 2-3 spots of drainage that came through his dressing but it was not soaked. LVN E stated if the dressing were soaked it would have needed to be changed. LVN E viewed the picture dated 12/11/2025 and stated she never saw his dressings soiled like the picture, but if she did she would have changed it. LVN E stated wound care was done daily or three times a week and depended on what the wound care NP wanted. LVN E stated wound care orders were put in by LVN A. LVN E stated the charge nurse put admission orders for wounds in the system if LVN A was not at the facility, otherwise, LVN A would put the orders in. During an interview on 1/2/2026 at 11:43 AM, ADON stated that on 12/12/2025 Resident #1's dressing looked like he had fresh bleeding because wound care had not been done and was going to be done after lunch. ADON stated if staff saw that dressing was soiled there should have been an order for PRN changes so the nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 4 of 8 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few could have changed the dressing. ADON stated LVN A could have also changed the dressing if she was in the facility but if it was on the weekend the charge nurse could have changed the dressing. ADON stated when a resident was admitted , the charge nurse put the treatment orders in. ADON stated LVN A was to follow up on Mondays for any new admissions from the weekend. ADON stated that LVN A was responsible to review the wound care report and it should have been reviewed as soon as it was received. ADON stated the report usually was sent within 1-2 hours and at least on the same day after the wound care NP visit. ADON stated treatment orders should have matched the orders from the wound assessment report. ADON stated it was important that the orders matched so the resident can get the right treatment. ADON stated a risk for wound care being completed less than ordered is that the wound care NP had made decisions for treatment based on rounds and there was a risk for swelling, slowed healing and risk of infection. ADON stated any PRN dressing changes were to be documented on the TAR. During an interview on 01/02/2026 at 12:09 PM, CNA C stated that she worked with Resident #1 and recalled seeing dressing around both of his legs. CNA C stated that he had what looked like dried blood on the outside of the dressing but that LVN A had not done wound rounds at that time. CNA C stated she saw Resident #1's dressing like this at least two or three times. CNA C stated that when she saw his dressing like this, she let the nurse know and LVN A know. CNA C stated that the color on the dressing was dark red and there were one or two spots on each leg. CNA C stated anytime she saw a soiled bandage she would report it immediately to the nurse. During an interview on 01/02/2026 at 12:39 PM, LVN D stated that he did not work with Resident #1. LVN D stated that LVN A was responsible for wound care and if LVN A was not there the charge nurse was responsible. LVN D stated if the outer dressing was soiled or had dried blood it would need to be assessed to determine if it needed to be changed. LVN D viewed the picture dated 12/11/2025 and stated he would have removed the outer bandage and more than likely it would have needed to be changed. LVN D stated if it was changed PRN by the nurse it would have needed to at least be documented on a progress note and notate the type of discharge. LVN D stated wound care orders were put in by LVN A. LVN D stated orders from the provider should match what was in PCC. LVN D stated if wound care order was less frequent that what the provider ordered there was a risk because the nurse should ensured the dressing was not soiled or had signs of infection. During an interview on 01/02/2026 at 1:25 PM, the DON stated if a new admission came in after LVN A had left, the charge nurse put in wound care orders from the hospital. The DON stated that LVN A would assess and follow up the following day to ensure the hospital orders matched what was in the system and looked appropriate. The DON stated wound care NP came in once a week and sent a report by the following day at the latest. The DON stated the treatment orders in the wound report should have matched the orders that were in PCC. The DON stated that it was important that the orders matched because that was the provider's order. The DON stated that the order specified wound care for three times a week and if the order read twice a week there was a risk in infection. The DON stated she reviewed the order and the order stated twice a week and one for every 72 hours which was still considered twice a week. The DON stated LVN A reviewed the wound care report. The DON stated she tried to review things as well but did not review every single wound care report. The DON stated a lot of people should be laying eyes on stuff because we cannot always rely on one person. The DON stated if drainage could be seen, she expected staff to look for a PRN order and change the dressing. The DON stated first LVN A should have been called if she were there. The DON stated she never viewed Resident #1's wounds and never received a report that there was a lot of drainage. The DON stated if a PRN change was done, it would have been documented on the MAR/TAR or the nurse could have put in a progress note. During an interview on 01/02/2026 at 1:56 PM, the ADM stated that LVN A or the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 5 of 8 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm charge nurse put in wound care orders into PCC. The ADM stated if the charge nurse put wound care orders into PCC, then LVN A was expected to review and ensure they were accurate. The ADM stated that LVN A was expected to review the wound care report. The ADM stated it was expected to follow the order they had and she expected the orders to be up to date. During an interview on 01/02/2026 at 2:24 PM, the ADM stated there was no facility policy on following orders or updating orders from the physician. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 6 of 8 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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)

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 interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, maintaining medical records on each resident that are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for clinical records. The facility failed to document that Resident #1 had a care plan conference on 12/4/2025. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.Findings include: Review of Resident #1's face sheet reflected an [AGE] year-old man admitted on [DATE] and discharged on 12/20/2025 with diagnoses of unspecified systolic heart failure (heart does not contract forcefully to meet the body's need), personal history of poliomyelitis (viral disease that attacks central nervous system potentially leading to paralysis), cognitive communication deficit (difficulty speaking, listening, reading or writing caused by problems with thinking skills, memory and attention), dysphagia (difficulty swallowing), vascular dementia (occurs when damaged blood vessels reduce blood flow and oxygen to the brain impairing thinking, memory and behaviors), and peripheral vascular disease (circulation disorder where narrowed blood vessels reduce blood flow). Review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of 13 which indicated no cognitive impairment. Review reflected Resident #1 was at risk of developing pressure ulcers. Review reflected Resident #1 had 5 venous and arterial ulcers (caused by poor blood flow from narrowed arteries creating punched-out wounds) and included infection of the foot and other open lesions on the foot. Review of Resident #1's baseline care plan reflected a date of 11/25/2025 and no discharge plans. Review of care conference note dated 11/26/2025 reflected an admission / baseline care plan conference was held on 11/26/2025 with Resident #1's RP via phone. Review reflected Resident #1's conditions were reviewed at admission and present conditioners were barriers to wound healing were reviewed. The care conference note was signed by MDS F. Review of Resident #1's progress notes reflected there was no care plan conference meeting documented for 12/04/2025. Review of Resident #1's assessments reflected there was no care plan conference meeting documented for 12/04/2025. During an interview on 01/02/2026 at 11:08 AM, LMSW stated a few care plan conference were held for Resident #1. LMSW stated there were at least 2 or 3. LMSW stated that MDS nurse was supposed to put in a note for the care plan conference and she did not put it in. LMSW stated that MDS nurse was no longer at the facility. LMSW stated there was a care plan meeting held on 12/04/2025 at 2:00 PM and LVN A, and DOR were present. LMSW stated that the nurse was responsible to put in care plan conference notes because it was a lot of medical questions. LMSW stated she sometimes had to remind the nurse. LMSW stated it was important that the note be put in each time and to document any concerns that were discussed. LMSW stated she reviewed the note was put in at least once every three more, but sometimes more frequently. LMSW stated what is the point of having the meeting if it's not going to be documented During an interview on 01/02/2026 at 11:26 AM, DOR stated he participated in the care plan conference on 12/04/2025. During an interview on 01/02/2026 at 11:42 AM, ADON stated that documentation of care plan meetings was supposed to be done by the MDS nurse or LMSW. ADON stated it was important to document meetings for the records. During an interview on 01/02/2026 at 1:07 PM, MDS F stated she has worked at the facility for about 2 months. MDS F stated she was in training until about 2 weeks ago. MDS F stated during a care plan conference each section in the note is put in by the respective discipline, but sometimes she had to fill in other departments' parts. MDS F stated she participated in a care plan conference for Resident #1 when he first admitted but not any other meetings. MDS F stated she thought there were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 7 of 8 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete more meetings but that those were not actual care plan meetings. MDS F stated what determined if a meeting was an actual care plan meeting was if there was an emergency circumstance or if something needed to be addressed. MDS F stated if there was a meeting it should have been documented at least in a progress note. During an interview on 01/02/2026 at 1:25 PM, the DON stated LMSW should document that the meeting occurred and who was present. The DON stated she hoped documentation was completed within a few days. The DON stated any care plan meeting should be documented even if it was brief note with concerns discussed. During an interview on 01/02/2026 at 1:56 PM, the ADM stated she knew there was a care plan meeting held on 12/04/2025 because Resident #1's RP came in to do admission paperwork that day. The ADM stated that she expected if any care plan is held there would be some kind of note. The ADM stated she expected MDS F or a nurse to document the note or LMSW should document. The ADM stated it was important to document because that is how the staff care for the resident and any family concerns should have been documented and who participated in the meeting. Review of facility policy dated July 2017 titled Charting and Documentation reflected all services provided to the resident, progress towards care plan goals, or changes in the resident's medical condition. shall be documented in the resident's medical record. Event ID: Facility ID: 675596 If continuation sheet Page 8 of 8