Health inspection·December 18, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm BIMS score of 10 indicating moderately impaired of cognition with no mood symptoms in the last 14 days and no behavior symptoms in the last 7 days. Record review of physician''s orders dated 12/18/24 indicated Resident #42 was prescribed trazadone 50 mg at bedtime for depression with a start date of 11/19/24. Residents Affected - Some Record review of Resident #42''s December 2024 MAR indicated she received trazadone 50 mg daily at bedtime for depression with a start date of 11/19/24. Record review of Resident #42's care plans printed 12/17/24 did not indicate Resident #5 received the antidepressant medication trazadone. During an observation 12/17/24 at 09:54 a.m., Resident #42 was lying in bed, he said he was unsure of what medications he received. 3. Record review of a face sheet indicated Resident #87 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs) and major depressive disorder (a serious mental illness that affects how people feel, think, and act). Record review of a PASRR (Preadmission Screening and Resident Review) level 1 Screening dated 3/5/24 indicated Resident #87 was PASRR positive due to a mental illness. Record review of an annual MDS assessment dated [DATE] indicated Resident #87 had a BIMS score of 13 indicating her cognition with intact and she was currently by state level II PASRR process to have serious mental illness. Record review of a quarterly PASRR Comprehensive Service Plan (PCSP) dated 09/05/24 indicated Resident #87 was refusing PASRR services. Record review of a care plan last updated 09/20/24 indicated Resident #87 had no care plan identifying she was PASRR positive and was refusing PASRR services. During an interview on 12/17/24 at 9:57 a.m., Resident #87 said she felt well balanced and good at the facility. She said she was receiving psychiatric services. She said she didn't need other services and had refused services offered in the PASRR meetings. During an interview on 12/18/24 at 10:48 a.m., LVN C said she was providing care for Resident #28 and #42 on 12/18/24. She said Resident #28 received hospice services and should have been care planned for the hospice services with goals and interventions and was not. She said Resident #42 received trazadone daily and should have been care planned for trazadone and was not. LVN C said the Unit Managers were responsible for care plans. During an interview on 12/18/24 at 10:50 a.m., Unit Manager A said she was responsible for care planning Resident #28's hospice goals and interventions. She said the goals and interventions should have been care planned but were not. Unit Manager A said she was responsible for care planning Resident #42's trazadone. She said it should have been care planned but was not. She said they were overlooked. Unit Manager A said she was educated on care plans and was aware to care plan the hospice goals and interventions and the antidepressant medication. She said the resident risk of Resident #28 not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676444 If continuation sheet Page 2 of 3 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 676444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonne Vie 8595 Medical Center Boulevard Port Arthur, TX 77640 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some care planned for her goals and interventions for hospice and Resident #42's antidepressant medication was the nurses could be unaware of the care and services the resident's received. During an interview on 12/18/24 at 11:08 a.m., MDS Nurse D said she was responsible for writing PASRR care plans. She said Resident #87 qualified for PASRR services but was refusing the services. She said the resident should have a care plan to address that she was PASRR positive, refused PASRR services, and quarterly meetings were being held to offer services and document Resident #87's refusal. She said she just overlooked writing a PASRR care plan because the resident was not receiving PASRR services. She said she had received PASRR training through HHSC, her corporate office, and webinars. She said a possible negative outcome of not having a PASRR care plan was staff would not be aware Resident #87 was PASRR positive, refused services, and the quarterly meetings held. During an interview on 12/18/24 at 11:18 a.m., the DON said she and other nursing administration were responsible for overseeing care plans and nursing administration met quarterly to review care plans for accuracy. She said the nursing staff were educated on accuracy and completeness of care plans. She said the missed care plans were overlooked. The DON said the resident risk of missed care plans was the potential risk of the nurses being unaware of the resident plan of care. She said she expected all care plans to be updated and completed timely. During an interview on 12/18/24 at 11:22 a.m., the Administrator said nursing was responsible for completed care plans. He said the staff were educated on care planning. The Administrator said the resident risk of services or medication not care- planned was potentially the nurses may not know the plan of care. He said he expected all care plans to be completed timely and accurately. Record review of a facility policy titled Care Plans, Comprehensive Person-Centered revised March 2022 indicated . The comprehensive person-centered care plan: a. includes measurable objectives and time frames; B. describes the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASRR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice and problem areas and conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676444 If continuation sheet Page 3 of 3