Health inspection·October 19, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 maintain medical records that were complete and accurate on four of six residents (Residents #1, #2, #3, #4) reviewed for resident records. The facility failed to ensure the medical records for Residents #1, #2, #3, and #4 included physician orders and consents for placement in the facility's secure unit as specified in the facility's policy. This failure could place residents at risk of involuntary seclusion. Findings included: Review of Resident #1's undated admission Record revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included unspecified psychosis, depression, anxiety, and seizures. Review of Resident #1's quarterly MDS, dated [DATE] revealed a BIMS score was not calculated based on her medical condition. Her Functional Status revealed she required limited assistance with all of her ADLs. Review of Resident #1's care plan, dated 09/05/23, revealed she had impaired safety awareness requiring a secured unit, and a deficit in memory, judgement, and decision making related to brain deterioration. Review of Resident #1's Elopement Risk Assessment, completed on 09/04/23, revealed she had previous elopements while living at home and verbalized not wanting to be at the facility. Review of all of Resident #1's physician orders revealed she had no order to admit to a secured unit. Review of Resident #1's EHR revealed no consent for admitting her to a secured unit. Review of Resident #2's undated admission Record revealed the resident was an 83-yea-old female admitted to the facility on [DATE] with diagnoses that included dementia, chemical imbalance in the brain, depression, and anxiety. Review of Resident #2's admission MDS, dated [DATE], revealed a BIMS score was not calculated based Page 1 of 3 676176 676176 10/19/2023 Crowley Nursing and Rehabilitation 920 E Fm 1187 Crowley, TX 76036

F 0842 on her medical conditions. Her Functional Status indicated she required limited assistance with her ADLs. Level of Harm - Minimal harm or potential for actual harm Review of Resident #2's care plan, dated 09/18/23, revealed she had impaired safety awareness requiring a secured unit. Residents Affected - Some Review of Resident #2's Elopement Risk Assessment, dated 09/04/23, revealed she had a history of elopement attempts at another facility, and an expressed desire not to be at the facility. Review of all of Resident #2's physician orders revealed she had no order to admit to a secured unit. Review of Resident #2' EHR revealed no consent to for admitting her to a secured unit. Review of Resident #3's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included anxiety, vitamin deficiency, high blood pressure, and osteoporosis. Review of Resident #3's admission MDS, dated [DATE] revealed a BIMS score was not calculated based on her medical conditions. Her Functional Status revealed she required limited assistance with her ADLs. Review of Resident #3's care plan, dated 10/04/23, revealed she had impaired safety awareness requiring a secured unit. Review of Resident #3's Elopement Risk Assessment, dated 10/04/23, revealed she had a history of elopement attempts at another facility and an expressed desire not to be at the facility, Review of all of Resident #3's physician orders revealed she had an order to admit to the secured unit. Review of Resident #3's EHR revealed no consent to admit her to a secured unit. Review of Resident #4's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included chemical imbalance in the brain, kidney failure, Parkinson, and heart disease. Review of Resident #4's admission MDS, dated [DATE], revealed a BIMS score was not calculated based on her medical conditions. Her Functional Status indicated she required limited assistance with her ADLs. Review of Resident #4's care plan, dated 09/28/23, revealed she had poor safety awareness, at risk for acute confusion episodes, and impaired thought processes. Review of Resident #4's Elopement Risk Assessment, dated 09/16/23, revealed she had a history of elopement attempts at another facility, and an expressed desire not to be at the facility. Review of all of Resident #4's physician orders revealed no order to admit her to a secured unit. 676176 Page 2 of 3 676176 10/19/2023 Crowley Nursing and Rehabilitation 920 E Fm 1187 Crowley, TX 76036

F 0842 Review of Resident #4's EHR revealed no consent to admit her to a secured unit. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Secure Care Environment policy, revised August 2014, reflected: Residents Affected - Some .2. The need for admission to the Secured Care Environment must have a physician's order and consent for placement Interviews on 10/19/23 with the Responsible Party for Residents #1, #2, #3, and #4 revealed they were aware of the resident being on the secured unit and had verbally consented to it. Interview on 10/19/23 at 2:00 PM with the DON revealed she was not aware of the need for a consent or physician order. She stated the risk of not having an order or consent was involuntary seclusion on the secured unit. Interview on 10/19/23 at 2:20 PM with the Administrator revealed the consents were supposed to have been added to the admission Packet, but had not been done. He stated the physicians were aware of the need for an order to admit to the secured unit and he would follow up with them. 676176 Page 3 of 3