Health inspection·October 17, 2024

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 residents have the right to formulate an advance directive for 1 of 24 residents (Resident #279) reviewed for advanced directives. The facility failed to maintain medical records on each resident that are complete, and accurately documented for Resident #279. This failure could affect residents by not having their preferences honored concerning advanced directives . Findings included: Record review on [DATE] of Resident #297's electronic face sheet revealed an [AGE] year-old female, admitted on [DATE] with a DNR status and a diagnosis of, unspecified fracture of right femur, and heart disease. Resident #297's Record Review on [DATE] of Resident #297's MDS Section C Cognitive Status, indicated the residents BIMS was 13 (cognitively intact). Record review on [DATE] of Resident #297's physician's orders dated [DATE] revealed there was an order for DNR. Resident #297's CP (Care Plan) dated [DATE] revealed she had a MPA (Medical Power of Attorney) on file with a Full Code status. Record review on [DATE] of Resident #297's electronic health record from [DATE] through [DATE] revealed there was no evidence of the following: *Advanced Directive for Out of Hospital Do Not Resuscitate Order (OOH-DNR) form; *Progress notes related to the DNR status; *Preadmission Advanced Directive Information form; *Advanced Directive for Out of Hospital Do Not Resuscitate Order (OOH-DNR) verbal assessment. During an interview and Record Review on [DATE] at 10:30 AM the DON stated Resident #297's code status was DNR and had documentation of the Physician order in the electronic chart. The DON stated there was a book at the nurse's station that revealed if residents had a DNR code status DNR, indicated (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 2 Event ID: 675633 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 675633 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holland Lake Rehabilitation and Wellness Center 1201 Holland Lake Dr Weatherford, TX 76086 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)