Health inspection·July 24, 2025

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 interview, and record review, the facility failed to ensure in accordance with professional standards and practices, the medical records on each resident were accurately documented for 1 of 7 residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure LVN A accurately documented on Resident #1's medical record the time of physician notification in the progress note dated 7/15/25. This failure could place residents at risk of emergency situations not being accurately documented, leading to confusion on what occurred when.Findings included:Record review of the face sheet dated 7/24/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including syncope and collapse (fainting, or sudden temporary loss of consciousness), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), hypertension (elevated blood pressure), and pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and heart). Record review of the admission MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #1 used a walker for mobility. The MDS indicated Resident #1 required partial assistance with indoor mobility and transfers. Record review of the care plan last revised 6/30/25 indicated Resident #1 was at risk for falls related to muscle weakness, unsteady gait, and syncope (fainting). Record review of the incident report dated 7/15/25 written by LVN A indicated Resident #1 was found lying in the floor. The incident report indicated Resident #1 had ambulated to her personal bathroom without her assistive device and fallen to the floor. The incident report indicated Resident #1 was non-responsive to verbal or physical stimulation. The incident report indicated Resident #1's physician was contacted by the facility at 11:00 p.m. and gave an order to send her to the emergency room. Record review of the progress note dated 7/15/25 written by LVN A indicated Resident #1 was found on the floor. The progress note indicated Resident #1 had a decreased blood pressure and decreased pulse. The progress note indicated Resident #1's physician was notified at 10:30 p.m. Record review of the Call for Service Report dated 7/22/25 from EMS indicated on 7/15/25 EMS received a call from the facility at 11:02 p.m. The Call for Service report indicated EMS was on the scene at the facility at 11:07 p.m. on 7/15/25. During an interview on 7/23/25 at 4:40 p.m. CNA B said she was working the night shift on 7/15/25 and was the staff member who found Resident #1 lying in the floor. CNA B said she found Resident #1 in the floor just a little before 11:00 p.m. CNA B said she made sure Resident #1 was breathing and then ran to get the nurse. CNA B said she had come on shift at 10:00 p.m., got report from the previous CNA, gathered her supplies, and started making rounds. CNA B said while making her first round was when she found Resident #1. During an interview on 7/23/25 at 4:43 p.m. LVN A said she was working on 7/15/25 when Resident #1 was found in the floor. LVN A said it was a few minutes before 11:00 p.m. when she was notified of Resident #1 being in the Page 1 of 2 676049 676049 07/24/2025 Legend Healthcare and Rehabilitation - Paris 520 SE 8th St Paris, TX 75460

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few floor. LVN A said she ensured Resident #1 was breathing, obtained her vitals, notified the physician, called EMS, and then notified the family. LVN A said the time documentation discrepancy for physician notification between the incident report and progress note was her fault. LVN A said she completed her incident report with the correct times and then when she completed her progress noted she clicked 10:30 p.m. for physician notification time. LVN A said she did not realize her mistake until the following day, and it was too late to change the documentation. LVN A said she had 2 issues going at the same time 1 with Resident #1 and another resident in the memory care unit which resulted in the time discrepancies. During an interview on 7/24/25 at 11:17 a.m. the Physician said he was unsure of what time he was contacted by the facility regarding Resident #1 on 7/15/25. The Physician said he knew the facility had woken him up when they called on 7/15/25 to report Resident #1 had fallen. During an interview on 7/24/25 at 11:23 a.m. the DON said the facility did not have a policy regarding accuracy of documentation. During an interview on 7/24/25 at 12:25 p.m. the DON said she expected nursing documentation to reflect a description of what was going on (incident, change of condition, etc.) and the action taken. The DON said time of notifications should be the same on an incident report and progress note. The DON said the importance of accuracy of documentation was to paint an accurate picture of what was going on and the actions taken at the time. 676049 Page 2 of 2