Health inspection·August 22, 2024

F 0583 Keep residents' personal and medical records private and confidential. 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 the residents' right to privacy for 1 (Resident #1) of 5 residents reviewed for privacy. Residents Affected - Few The facility failed to ensure Resident #1's BIMS score and medical diagnosis was not given to non-family or non-medical persons in the building. These failures could allow residents' protected HIPAA information to be shared with individuals who do not have a need or right to know which could place residents at a risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female with an initial admission date of 7/30/24, with diagnoses which included metabolic encephalopathy (a neurological disorder that occurs when a chemical imbalance in the blood affects the brain), arthritis, dementia, and anxiety disorder. Record review of Resident #1's quarterly MDS assessment section C, cognitive patterns, dated 8/21/24 reflected a BIMS score of 10 (moderate impairment). During a phone interview on 8/19/24 at 2:35 p.m., the ombudsman stated that she had a call from Resident #1's Family Member A who stated that someone at the building on 8/5/24 gave out Resident #1's BIMS and diagnosis to someone they should not have. She stated that there is an ongoing court case involving Resident #1 and Family Member B. She stated that a notary came to the facility and attempted to get Resident #1 to sign documentation to not evict Family Member B off the property back home. She stated that there was an argument, and some medical information was given out to the notary. She stated she followed up on the incident on 8/7/24 and went to the facility and asked who in the building gave away this information. She stated that the administrator stated, she was the one who gave out this information to the notary. She stated the administrator stated, she gave out the information to calm everyone down. During a phone interview on 8/19/24 at 2:55 p.m., Family Member A stated that on august 5th 2024 around 5:30 p.m., a notary came to the facility. She stated that the notary was trying to get Resident #1 to sign documentation which she should not sign. She stated that the next day august 6th 2024 there was a court case in which the notary at the facility shared Resident #1's diagnosis and BIMS score. She stated she has no idea who gave this information to the notary, and this should never have happened. She stated that was when she decided to reach out to the ombudsman to figure out who gave Page 1 of 3 676376 676376 08/22/2024 Silver Spring 1690 N. Treadway Blvd. Abilene, TX 79601

F 0583 this information away. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/19/24 at 3:15 p.m., the Administrator stated that there was an incident on August 5th, 2024, in which a notary from the court was at the facility. She stated that Resident #1's Family Member A came and banged on her door and stated that the notary in the building should not be there and is not sure why he was there. She stated that there had been an ongoing court case, and this was roughly the 4th time the case was trying to be determined. She stated that in open conversation she stated to both the notary and Family Member A that they needed to know the residents BIMS score to determine if she had the ability to make the decision on her own. She stated that once she found out Resident #1's BIMS score she stated out loud to a group of employees and the notary. She stated she was trying to help the situation. Residents Affected - Few Record review of Facility Policy dated December 2006; titled Confidentiality of Information indicated: Policy statement-our facility shall treat all resident information confidentially. Policy interpretation and implementation: 1. The facility will safeguard all resident records, weather medical, financial, or social in nature, to protect the confidentiality of the information. 676376 Page 2 of 3 676376 08/22/2024 Silver Spring 1690 N. Treadway Blvd. Abilene, TX 79601

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 2 newly admitted residents (Residents #2) reviewed for baseline care plan. The facility failed to develop a baseline care plan for Resident #2. These deficient practices could place residents at-risk for decreased quality of life, improper care, and injury. The findings were: Record review of Resident #2's face sheet dated 8/20/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included end stage renal disease, hyperlipidemia, and hypertension. Record review of Resident #2's baseline care plan reviewed 8/20/24 revealed no data available. During an interview on 8/19/24 at 4:45 p.m., MDS C stated that Resident #2 came in on a Friday 6/28/24 and left AMA early Monday 7/1/24 morning. She stated that the nurses interim plan of care was completed upon admission for Resident #2. She stated but no baseline care plan was completed for the resident. She stated that the resident was not here long enough to get the care plan completed because it was through a weekend, and she left before they started on 7/1/24. She stated a baseline care plan should be completed on every resident within 48 hours. During an interview on 8/22/24 at 11:45 a.m., the administrator stated a baseline care plan should be completed within 48 hours of being admitted into the facility. During an interview on 8/22/24 at 12:25 p.m., the DON stated that a baseline care plan should be done within 48 hours of the resident being admitted . She stated that sometimes they use the interim plan of care to get an initial care plan done for a resident. She stated however, the interim plan of care documentation is incomplete and there is no baseline care plan completed Resident #2. She stated this was a miss by the staff, even if it was a weekend, it should have been completed and it was not. Record review of Facility Policy dated December 2016; titled Care Plans-Baseline indicated: Policy statement-A baseline pan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. 676376 Page 3 of 3