Health inspection·July 9, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents review for resident rights. RN A failed to notify Resident #1's family when a new medication order for antibiotics, to treat a urinary tract infection, was initiated on 06/14/2024. This failure put residents at risk for not having their representative notified and aware of their current medical status. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included retention of urine unspecified, pain unspecified, dementia (a general term for a decline in cognitive function that interferes with daily life) in other disease classified elsewhere, acute kidney failure (a sudden and rapid decline in kidney function). Face sheet also reflected Resident #1 had a Responsible Party. Review of the quarterly MDS assessment for Resident #1 dated 06/12/2025 reflected a BIMS score of 3, indicating severe cognitive impairment. It reflected he had an indwelling catheter. Review of the care plan for Resident #1 initiated 06/05/2025 reflected the following: [Resident #1] has ADL Self Care Performance Deficit relating to dementia, impaired limited mobility, he had impaired cognitive function/dementia or impaired thought processes related to dementia, Bims. Interventions included: Communicate with the resident/family/caregivers regarding residents' capabilities and needs. Review of Resident #1's MAR reflected: Sulfamethoxazole- Trimethoprim (Bactrim DS -is an antibiotic prescribed to treat various bacterial infection) Tablet 800- 160 MG Give 1 tablet by mouth every 12 hours for UTI (E. coli) for 7 Days -Start Date- 06/14/2025. Review of Resident #'s progress notes dated 06/14/2025 at 10:05 pm created by RN A reflected: Note Text: The order you have entered Sulfamethoxazole-Trimethoprim Tablet 800-160 MG Give 1 tablet by mouth every 12 hours for UTI (E. coli) for 7 Days Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. Review of Resident #1's progress notes for 06/14/and 06/15/2025 did not reflect Resident #1's family was notified of a new antibiotic order for UTI. Review of Resident #1's NP's progress notes dated 06/16/2025 at 5:45 pm reflected: Acute UTI -urine cx collected 6/10/25, resulted 6/14/25 w/ +E. coli, 50-99k- d/t confusion and repeated falls treating for UTIBactrim DS 800/160 mg q12 ordered 6/14/25, ED 6/21/25 Review of Resident #1's progress notes dated 06/22/2025 at 10:58 am reflected Resident #1 was discharged home. During an interview on 07/09/2025 at about 2:19 pm, RN A stated she worked the 2-10 pm shift on the 700 and 800 halls. RN A stated her name was noted on Resident #1's antibiotic order because she confirmed the order put in by the NP. RN A stated the NPs usually put new orders in the computer and the nurses confirmed that they would start the order. RN A stated, I don't remember notifying the family or documenting on the antibiotic order. It was important to notify the family of new medication orders so they can know and sometimes the family would disagree with Page 1 of 2 676345 676345 07/09/2025 Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few treatment plans. The family was always here, and we are always telling them things, maybe it slipped my mind. During an interview on 07/09/2025 at about 3:11 pm, the DON stated he expected the nursing staff to notify the family members for any new medication order before administering the medication because sometimes the family would decline the treatment plan, and to make sure they were aware and informed. The DON stated Resident #1's family was at the facility most of the time, and they were notified of changes in person. The DON stated he expected nursing staff to document on new orders. The DON stated he was aware that the NP spoke with Resident #1's RP a lot of time to discuss POC. The DON reviewed Resident #1's progress notes and noted there was no documentation of Resident #1's family being notified of new antibiotic orders. Review of the facility's policy titled Change of Condition revised January 2024 reflected: Policy: To identify and evaluate a change in condition and notify the Physician and Responsible Party when indicated. A significant change in Resident's status is any sign or symptom that is: Acute or sudden onset A marked change (i.e., more severe) in relation to usual signs and symptoms New or worsening symptoms3. Document date, time Physician, Responsible Party was notified of findings from the evaluation and any new orders obtained. 676345 Page 2 of 2