Health inspection·June 6, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure a care plan was developed to address Resident #1's psychiatric behaviors such as wandering, insomnia, aggitation, and anxiety. This failure could place residents at risk of not having their individualized needs met, a delay in services, and not receiving adequate care. Findings included: Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, type II diabetes , stroke, and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS assessment, dated 04/17/24, reflected a BIMS of 11, which indicated a moderate cognitive impairment. Section D (Mood) reflected he often felt lonely or isolated from those around him. Section E (Behavior) reflected he had no hallucinations, delusions, or physical/verbal behavioral symptoms directed towards others. Record review of Resident #1's quarterly care plan, revised 05/09/24, reflected he used antidepressant medication related to depression and anti-anxiety medications related to anxiety disorder with interventions of administering medications as ordered by the physician. There was no mention of psychiatric behaviors. Record review of Resident #1's physician order, dated 01/15/24, reflected Depakote Oral Tablet Delayed Release 125 MG - Give two tablets by mouth three times a day for behavioral disturbance. Record review of Resident #1's physician order, dated 03/18/24, reflected Zoloft Oral Tablet - Give 100 mg by mouth one time a day for anxiety/depression. Record review of Resident #1's physician order, dated 05/14/24, reflected Buspirone HCl Tablet 5 MG Give two tablets by mouth three times a day for anxiety. Page 1 of 3 675937 675937 06/06/2024 Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613

F 0656 Record review of Resident #1's psychiatric assessment, dated 05/27/24, reflected the following: Level of Harm - Minimal harm or potential for actual harm [Resident #1] is being seen today for the management of psychotropic medications and side effects, and to monitor the effect of medication and for dosage adjustment. [Resident #1]'s psychotropic medication is beneficial in this case to control their psychiatric symptoms and to manage [Resident #1]'s condition and to prevent relapse or hospitalization. Residents Affected - Few Review of Resident #1's progress notes, dated 01/04/24 at 1:10 AM, relected the following: [Resident #1] awake, in hallway, looking at clock on wall, and then back to his room. Review of Resident #1's progress notes, dated 01/06/24 at 12:43 AM, reflected the following: [Resident #1] disoriente to time, even asking staff for time, ambulatin to various clocks on wall to look at time, and then going to bed. Review of Resident #1's progress notes, dated 01/15/24 at 12:10 AM, reflected the following: [Resident #1] has been up and about, constantly coming to nurse, asking for a job, being difficult to redirect. He propels in dining room, drinking from pitchers lying about, and then back to his room. Review of Resident #1's progress notes, dated 01/15/24 at 8:06 PM, reflected the following: [Resident #1] walked out the front door of the building, following the lab tech out . Review of Resident #1's progress notes, dated 01/15/24 at 9:50 PM, reflected the following: DON was notified following [Resident #1]'s exit-seeking and leaving through the front door. During an interview on 06/06/24 at 11:43 AM, Resident #1's FM A stated she was aware he was on a few psychotropic medications. She stated the facility did inform her. She stated since being put on the psychiatric medications he was more calm, less anxious, and he slept through the night. During an interview on 06/06/24 at 12:32 PM, the ADM stated the MDSC was normally responsible for care plans but any nurse could update them. He stated he would expect Resident #1's behaviors to be documented in his care plan. He stated care plans were important to be able to provide necessary care and not providing the best care possible could be a negative outcome if the residents' care plans were not complete and comprehensive. During an interview on 06/06/24 at 12:39 PM, the MDSC stated she was responsible for initial and quarterly care plans and when there was a change in a resident's condition. She stated things such as pain, ADLs, wounds, and falls should be care planned. She stated Resident #1's behaviors, such as his constant wandering, agitation, and confusion, should have been care planned . Record review of the facility's Comprehensive Person-Centered Care Plan Policy, revised December 2016, reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to 675937 Page 2 of 3 675937 06/06/2024 Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613

F 0656 Level of Harm - Minimal harm or potential for actual harm meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Residents Affected - Few 675937 Page 3 of 3