Health inspection·June 2, 2023

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 record review and interview, the facility failed to maintain clinical records on Resident #1 were complete, accurate, and in occordance with accepted professional standards and ptactice for 1(Resident #1) of 5 residents reviewed for accuracy and completness. The facility failed to document active treatment for Resident #1. This facility failure placed residents at risks for lack of appropriate interventions related to specific treatment. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] Diagnoses included myocardial infarction (a blockage of blood flow to the heart muscle) acute respiratory failure with hypoxia (acute or chronic impairment of gas exchange between the lungs and the blood) Rash and other nonspecific skin eruption, unspecified Dementia (memory loss), and Type 2 Diabetes (resist to insulin). Review of Resident #1's MDS dated [DATE] revealed Resident #1's BIMS summary score of 99. Resident # 1 is non-verbal. Review of Resident #1's care plan dated 9-8-2022 revealed Resident #1 focus documented pressure ulcer stage 3 to the posterior medial sacrum and posterior medial buttock.(full-thickness skin loss potentially extending into the tissue layer). Interventions continue current treatment as ordered, and change dressing PRN Q day Review of Resident #1's treatment administration record dated 5-28-2023 revealed Resident #1!'s treatment to clean on the posterior medial sacrum, apply anasept mixed with collagen, and cover with dry dressing Q day and PRN every day shift. Review of the treatment administration record revealed LVN A failed to sign off on treatment on May 11, 2023, May 19, 2023, and May 24, w2023. Interview was attempted on 05-27-2023 at 4:54 PM with Resident # 1. Resident #1 is nonverbal. Interview on 05-28-2023 at 12:45 PM with LVN A stated on the dates 5-11-2023, 5-19-2023, and 5-24.2023 she completed the treatment for Resident #1 but did sign off or document the treatment. LVN A stated the documentation should have been noted at the time of treatment. LVN A stated multitasking with other nursing duties she failed to document the treatment. LVN A stated it is important to sign (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: 676047 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 676047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Keene, Inc. 207 S Old Betsy Rd Keene, TX 76059 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)