Health inspection·July 3, 2024

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 maintain medical records on each resident, in accordance with accepted professional standards and practice, that were complete and accurate for 1 of 8(Resident #5) residents reviewed for resident records. The facility failed to ensure physician orders were followed and documented for Resident #5. This failure could place residents at risk of having errors with their care and treatment. Findings included: Record review of Resident #5's face sheet dated 06/26/2024 revealed a [AGE] year-old female admitted on [DATE] and discharged on 02/22/2024 with the following diagnosis hydronephrosis (kidney swells and cannot get rid of pee), difficulty walking, obstructive and reflux uropathy (urine cannot flow normally through urinary tract due to a blockage) and hypertension (high blood pressure). Record review of Resident #5's admission MDS dated [DATE] revealed Section-C Cognitive Patterns Resident #5 had a BIMS score of 14, meaning cognitively intact; Section H- Bladder and Bowel revealed Resident #5 had intermittent catheterization. Record review of Resident #5's physician orders revealed start date 02/17/2024 Nurse to straight cath patient if patient unable to void every 3 hours as needed for urinary retention. Record review of Resident #5's MAR for February 2024 revealed no evidence of urine output or monitoring every 3 hours. Record review of Resident #5's progress notes revealed no evidence of urine output or monitoring every 3 hours per physician order on 02/18/2024, 02/19/2024, and 02/20/2024. During an interview on 06/26/2024 at 3:15 PM the ADON stated she was educated on how to document when she was received her education for her license. The ADON stated she expected that nurses had been trained in school and they were also trained during orientation and provided in-service per facility need. The ADON stated her expectation would have been that staff document every 3 hours that Resident #5 had voided or needed to have been cathed, and the urine output should have been recorded. The affect on resident could have been resident not receiving the assistance/care needed. During an interview on 07/03/2024 at 10:25 AM the DON stated her expectation was that nurses follow (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: 676185 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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)