Health inspection·September 10, 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 interviews and record reviews, the facility failed to ensure medical records were complete and accurately documented for 1 of 3 residents (Residents #1) whose assessments were reviewed. The facility failed to ensure Resident #1's Shower log, dated 06/17/2024, correctly documented the resident as receiving showers. This failure could place residents at-risk for inadequate care and services due to an inaccurate assessment. The findings were: Record review of Resident #1's electronic face sheet, dated 9/5/24 revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include Dementia, Malnutrition, and obstructive pulmonary disease (a group of lung diseases that make it hard to breathe by blocking airflow to the lungs). Record review of Resident #1's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12, which indicated the resident's cognition was intact. Record review of Resident #1's care plan dated 9/5/24 did not indicate Resident #1 refused showers. Record review of Resident #1's shower log dated 8/11/24 to 9/3/24 indicated Resident #1 was to receive showers on Monday, Wednesday, and Friday. The shower log indicated Resident #1 refused showers on 8/11/24, 8/12/24, 8/13/24, 8/14/24, 8/15/24, 8/17/24, 8/20/24, 8/22/24, 8/27/24, 8/29/24, 8/31/24, 9/1/24, 9/2/24, and 9/3/24. During an interview on 9/6/24 at 1:05 PM, Resident #2 stated that him and Resident #1 kept to themselves. He stated resident #1, was not very verbal, he may say yes or no or grunt but nothing more. He stated Resident #1 would get his showers every time. He stated he never heard Resident #1 ever refuse showers. During an interview on 9/5/24 at 2:05 PM, SA A stated that Resident #1 never refused showers. She stated that she worked Monday through Friday and that is all she does was resident showers on hallway 200 and 300. She stated she does have a few residents that refused showers, but in general, most Page 1 of 2 675928 675928 09/10/2024 Sienna Nursing and Rehabilitation 2510 W 8th Street Odessa, TX 79763

F 0842 residents like to take their showers. She stated Resident #1 never would refuse anything to be honest. Level of Harm - Minimal harm or potential for actual harm During an interview on 9/5/24 at 3:15 PM, SA A stated she must have been going too fast and mis-clicked on refusal for shower instead of total dependance. She stated Resident #1 always got his showers and she knows that she gave Resident #1 the showers on every date listed as refused or not given. Residents Affected - Few During an interview on 9/6/24 at 3:25 PM, the ADON stated that Resident #1 never refused showers. She stated that SA A must have mis-clicked the documentation because the resident never refused showers. She stated this was a documentation error. She stated this can be harmful to the resident because it could cause inadequate care for the residents by not documenting correctly. Record review of the facility's Policy titled: Documentation dated 2003 indicated: The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 675928 Page 2 of 2