Health inspection·December 8, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the right for a resident to refuse or discontinue treatment for 1 of 5 Residents (Resident #1) whose records were reviewed for resident rights. The DON, failed to stop Depakote after Resident #1's RP requested the medication be stopped immediately on [DATE]. This deficient practice could affect any resident and could result in residents believing their right to refuse a medication does not matter. The findings were: Record review of Resident #1's admission Record, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and dementia, unspecified (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems. Symptoms may also include personality changes). Record review of Resident #1's [DATE] Quarterly MDS revealed Resident #1 had a BIMS score of 99, which indicated Resident #1 could not complete the assessment. Resident #1 had unclear speech, was rarely/never understood others and was rarely/never able to be understood by others. Resident #1 was always incontinent of his bowels and bladder. Resident #1 required substantial/maximal assistance with eating. Resident #1 was dependent on toileting hygiene, showers/baths, and personal hygiene requiring the assistance of two or more helpers. Review of Resident #1's physician orders for [DATE] revealed the following orders: Start Date [DATE] End Date [DATE] Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for MOOD [AFFECTIVE] DISORDER. Review of Resident #1's physician order for Start Date [DATE] End Date [DATE] revealed the following order: Start Date [DATE] End Date [DATE] Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for MOOD [AFFECTIVE] DISORDER. Review of Resident #1's [DATE] MAR revealed he received Depakote 250 mg Oral Tablet Delayed Release two times a day from [DATE] through [DATE]. The morning dose on [DATE], was refused by Resident #1 and the evening dose was not taken due to Resident #1's unresponsiveness and his being sent to the hospital where he expired. Review of Resident #1's progress note dated [DATE] at 03:46 pm revealed DON A wrote Nursing Note Skilled nurse received a call from Resident #1's RP, who stated she never gave consent for Depakote and expressed concern that Resident #1 appears very sleepy. She requested that the medication be discontinued immediately. After reviewing the chart, I explained to her that verbal consent had been obtained from her over the phone. RP further stated that she does not want any physician other than PCP to prescribe medications for Resident #1 and that she had not given consent for any other providers to see him. I reminded her that she had previously provided consent to myself and the facility administrator, and that due to the patient's behaviors, psychiatric services were initiated with consent on file. The medication in question is Depakote 250 mg PO BID for mood disorder. I contacted PCP's office to obtain discontinuation orders; however, the Page 1 of 6 676083 676083 12/08/2025 Brownsville Nursing and Rehabilitation Center 320 Lorenaly Dr Brownsville, TX 78520

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few office was closed for the weekend. I then called the on-call line and spoke with NP J, who advised that the medication is helping manage the patient's documented behaviors and recommended not discontinuing until PCP is consulted directly. This information was communicated to RP, who has been informed of the plan. We will await further orders from PCP on Monday. continue poc. During an interview on [DATE] at 09:05 am DON B stated when the RP told them to stop a medication, they would stop the medication even if they could not reach the physician to notify. DON B stated the resident or RP's wishes would be honored and they would put the medication on hold. She said the nurses were alerted to the medication hold and also notified during their daily meeting of the hold on the medication. She said the medication would show as on hold on the MAR. The DON stated she had not seen a policy for what to do when a resident or RP told them to stop a medication. During an interview on [DATE] at 10:13 am ADON E stated if the RP requested the medication be stopped, they would notify the RP they had to notify the doctor, and the doctor had to stop the medication. He said if the doctor said it was ok to stop the medication, they would stop it, but the doctor may say to leave the medication in place and the resident could refuse. ADON E stated if the doctor said to continue the medication, they would continue the medication and relay that information to the family. ADON E stated he did not think there was a policy on stopping medication at RP request. During an interview on [DATE] at 10:33 am Administrator D stated they did not have a policy on stopping medications when an RP requested a medication be stopped. During an interview on [DATE] 01:32 pm Resident #1's RP stated in August there was a Care Plan meeting that she and two family members attended. She said at the meeting the three of them told the administrator C and DON A they did not want Resident #1 on Depakote to stop giving it to him. She said they did not want Resident #1 on anything that sedated. RP stated she did not give verbal consent for Depakote in July and even if she did, it should have been stopped after that Care Plan meeting in August. RP stated she called DON A on [DATE]. She said she had found out Resident #1 was still being given the Depakote. She said she told DON A they did not want Resident #1 to take Depakote, and wanted it stopped immediately. She said DON A told her she had given verbal consent back in July for Resident #1 to get Depakote. RP stated she told DON A that she had never given consent for Depakote, and she wanted it stopped immediately. She said DON A stated he would have to talk to the doctor first and he would let her know what the doctor said. RP stated she was pretty sure they had to stop the medication when the family said stop the medication, but DON A said he had to talk to the doctor first. She said he told her that since it was Friday ([DATE]) and the doctor was not in the office, he would talk to the doctor on Monday ([DATE]). She said DON A had said he talked to NP J and NP J stated not to stop Depakote and talk to the doctor. RP stated she called the doctor's office because she felt she had a good relationship with the doctor so the Depakote could be stopped, so she called the doctor's office and spoke to OM I. RP stated the OM I told her DON A did not speak to the NP but had spoken to her. RP stated she tried to get in touch with DON A to ask him about it, but he did not respond to her texts or phone calls. During an interview on [DATE] at 02:30 pm MDS H stated she was the one who wrote the notes for the Care Plan meeting [DATE] for Resident #1. She said the RP attended in person and the two Family Members attended by Teams. She said she could not remember the meeting. She said she probably would not have put in the notes if the family requested the Depakote to be stopped. She said if the family wanted to stop a medication, she would have notified the ADON and the ADON would have taken care of it. During an interview on [DATE] at 03:48 pm APNP L for psychiatric services stated DON A sent the referral for services for Resident #1 on [DATE]. She said DON A put on the intake that PCP had made the referral. APNP L stated she had ordered Depakote for him. She said her name would be on the order because she was the one who ordered 676083 Page 2 of 6 676083 12/08/2025 Brownsville Nursing and Rehabilitation Center 320 Lorenaly Dr Brownsville, TX 78520

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it. APNP L stated she went back on [DATE] to see Resident #1 again and she wanted to add Seroquel. She said she told DON A if the family agreed to the Seroquel she would see the resident again, but she never heard back from DON A so she did not see Resident #1 again. During an interview on [DATE] at 11:32 am PCP's Office Manager stated Resident #1's RP called on [DATE] asking about a medication (Depakote). OM told her she was the Office Manager and not a nurse, but she would let the doctor know. OM I stated RP asked if the facility had called to let them know the family wanted the medication stopped. OM I stated RP told her she had never given consent to have her father on that medication (Depakote) and the family had not wanted Resident #1 on it. OM I stated she told RP that DON A called and spoke to her, but she had not given any orders. She said she explained to the RP she was just the Office Manager, not a doctor or NP, and could not order medications to be started or stopped. OM I stated she had the SNF phone and was answering the calls when DON A called on [DATE]. She said she explained to DON A, NP J was out of town and not working when he called. She said that she told him that NP J did not answer her phone on weekends, but she would give her the message on Monday ([DATE]). OM I stated she checked with NP J on [DATE] to see if any orders were given [DATE] through [DATE] for Resident #1. She said NP J told her she had been out of town and did not answer her phone on weekends. OM I stated NP J denied writing any orders or speaking with DON A. During an interview on [DATE] at 03:54 pm RN F stated if an RP or resident wants a medication stopped, they would document in the Progress Notes the RP's request, place the medication on hold, and notify the doctor. She said the request would go on the 24-hour report and it would also be passed on at shift report by the nurse who received the request and the discontinuation order by the doctor if one was received. She said sometimes the doctor would say to leave the medication on and obtain the resident refusal, but usually the doctor would discontinue the order. During an interview on [DATE] at 08:40 am, the Administrator stated there was not a policy concerning a family's request to stop medication or treatment. Review of facility policy, Exercising Your Rights as a Nursing Facility Resident State Long-Term Care Ombudsman Program dated [DATE] revealed, The Resident has the right: * To be treated with dignity and respect also means you have the right to make decisions about your life and care. Your facility must respect your choices and preferences. * To make choices about your care. You have the right to participate in your care and make choices about your care. This includes the right to:- Refuse any care or treatment.- Choose people to help you make decisions or make decisions for you when you are unable to. 676083 Page 3 of 6 676083 12/08/2025 Brownsville Nursing and Rehabilitation Center 320 Lorenaly Dr Brownsville, TX 78520

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure review and revision of comprehensive care plans for 1 resident (Resident #1) of 5 residents reviewed for comprehensive care plan revisions in that: The facility failed to review and revise Resident #1's comprehensive person-centered care plan to address the initiation of Depakote, an antiseizure medication used for mood disorder. This deficient practice could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs.The findings were: Record review of Resident #1's admission Record, dated 11/26/2025, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and dementia, unspecified (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems. Symptoms may also include personality changes). Record review of Resident #1's 07/22/2025 Quarterly MDS revealed Resident #1 had a BIMS score of 99, indicated Resident #1 could not complete the assessment. Resident #1 had unclear speech, was rarely/never understood others and was rarely/never able to be understood by others. Resident #1 was always incontinent of his bowels and bladder. Resident #1 required substantial/maximal assistance with eating. Resident #1 was dependent on toileting hygiene, showers/baths, and personal hygiene requiring the assistance of two or more helpers. Record review of Resident #1's psychiatric note dated 07/26/2025 at 09:00 am written by APNP L revealed an order for Depakote 250 mg twice a day. Record review of physician's orders revealed on 07/26/2025 at 10:20 am an order given by PCP for Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for MOOD [AFFECTIVE] DISORDER. Order was discontinued on 08/02/2025. Record review of physician's orders revealed on 08/02/2025 at 05:40 am an order given by PCP for Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for MOOD [AFFECTIVE] DISORDER. Order was discontinued on 10/07/2025. Record review of Progress Note for Resident #1 written by LVN G on 07/26/2025 at 10:16 am revealed APNP L ordered Depakote 250 mg twice a day by mouth. Record review of Progress Note for Resident #1 written by MDS H on 08/21/2025 at 05:46 pm revealed NURSING - Plan of Care Note Note Text : CARE PLAN MEETING HELD WITH RP, (and family members) VIA TEAMS MEETING. ADMINISTRATOR, DON, ADON'S AND CARE MANAGEMENT PRESENT. DISCUSSED WTIH FAMILY DECREASE IN BEHAVIORS. DISCUSSED MEDICATION INTERVENTIONS IN PLACE FOR MOOD DISORDER (DEPAKOTE)FAMILY AWARE PATIENT 1 TO 1 WITH RESIDENT WILL BE DISCONTINUED TOMORROW. FAMILY ALSO AWARE THAT PATIENT DOES CONTINUE TO REFUSE ADL CARE AND BECOMES AGITATED WITH INCONTINENT CARE. During an interview on 12/05/2025 at 04:45 pm ADON E stated if a medication needed a consent, it would be care planned. He said Depakote did not need labs since it was being given therapeutically for mood. ADON E stated best practice would be the nurse who gets the order for a medication (Depakote for mood disorder), would be the one who put it in the care plan, but any nurse could do that. During an interview on 12/05/2025 at 04:50 pm DON B stated Depakote would not need labs to check levels if the Depakote was being given for moods. She said if the Depakote were being given for seizures, there would be labs also ordered by the doctor. DON B stated if Depakote were ordered on a Saturday, the nurse who received the order would be the one who care planned the medication after the consent was signed. She said on Monday, the medication would be discussed at the morning meeting with the IDT. Record review of facility's Care Plan Revisions Upon Status Change Policy, dated 10/24/22, revealed:Policy:The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.Policy 676083 Page 4 of 6 676083 12/08/2025 Brownsville Nursing and Rehabilitation Center 320 Lorenaly Dr Brownsville, TX 78520

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Explanation and Compliance Guidelines:1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.2. Procedure for reviewing and revising the care plan when a resident experiences a status change:c. The team meeting discussion will be documented in the nursing progress notes.d. The care plan will be updated with the new or modified interventions. Record review of facility's Psychoactive Medication Management Policy, not dated, revealed:Upon noting an order for psychoactive medication on admission or initiation of therapy:5. Care plan the targeted behavior and for why the resident is receiving the medicationForms and Timing of Completion:5. Care Plan - upon initiation of medication. 676083 Page 5 of 6 676083 12/08/2025 Brownsville Nursing and Rehabilitation Center 320 Lorenaly Dr Brownsville, TX 78520

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for 1 resident (Resident #1) of 5 residents reviewed for quality of care, in that: The facility failed to consult with Resident #1's physician concerning the discontinuation of Depakote at RP's request. These failures placed residents in the facility at risk for not receiving care according to professional standards.The findings were:Record review of Resident #1's admission Record, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and dementia, unspecified (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems. Symptoms may also include personality changes). Record review of Resident #1's [DATE] Quarterly MDS revealed Resident #1 had a BIMS score of 99, indicated Resident could not complete the assessment. Resident #1 had unclear speech, was rarely/never understood others and was rarely/never able to be understood by others. Resident #1 was always incontinent of his bowels and bladder. Resident #1 required substantial/maximal assistance with eating. Resident #1 was dependent on toileting hygiene, showers/baths, and personal hygiene requiring the assistance of two or more helpers. Review of Resident #1's [DATE] MAR revealed he received Depakote 250 mg Oral Tablet Delayed Release two times a day from [DATE] through [DATE]. The morning dose on [DATE], was refused by Resident #1 and the evening dose was not taken due to Resident #1's unresponsiveness and his being sent to the hospital where he expired. Review of Resident #1's progress note dated [DATE] at 03:46 pm revealed DON A wrote I contacted PCP's office to obtain discontinuation orders; however, the office was closed for the weekend. We will await further orders from PCP on Monday ([DATE]). Review of Resident #1's progress notes dated [DATE] revealed DON A had no follow-up note concerning the discontinuation orders for Depakote at the RP's request. During an interview on [DATE] at 11:32 am, OM I stated she believed she called to follow-up with the facility on [DATE] concerning Resident #1 because she had not heard from DON A and was notified at that time Resident #1 was found unresponsive on [DATE], CPR was initiated, then he had been sent out to the hospital, and expired on [DATE]. Record review of facility's Charge Nurse job description not dated revealed:Essential functions: Communicate with resident's point of contact when they ask for a status update or if there is a change in condition. Residents Affected - Few 676083 Page 6 of 6