Health inspection·May 31, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **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 comprehensive person-centered care plan for each resident, consistent with the resident rights and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #39), reviewed for care plans. The facility failed to ensure Resident #31's care plan was revised to reflect an order for an alarm guard. This failure could place residents at risk of current needs not being met. Findings include: Record review of Resident #31's admission record, dated 05/31/2024, reflected the resident was an [AGE] year-old female with an admission date of 04/11/23. Resident #31had diagnoses which included dementia (general decline in cognitive activities), diabetes (sustained high blood sugar levels), cognitive communication deficit (problems with communication), and anxiety disorder (mental disorder associated with stress.) Record review of Resident #31's significant change status MDS assessment, dated 05/24/24, reflected a BIMS score of 3, which indicated Resident #31's cognition was severely impaired and had no behaviors of wandering. Resident #31 used a wander/elopement alarm daily. Resident #31 used a wheelchair as a mobility device. Resident #31 was transferred from the secured unit to the general population on 05/07/24. Record review of Resident #31's physician orders reflected an order for an alarm guard, to the left arm, start date 05/07/24. An order, dated 05/29/24, reflected an order for the alarm guard to the left ankle. Record review of Resident #31's care plans reflected the resident required a wander guard (alarm guard) bracelet and was at risk for injury from wandering in an unsafe environment, as evidenced by dementia and Alzheimer's, date initiated on 05/29/24. Observation on 05/29/24 at 11:00 AM revealed Resident #31 in bed, wearing an alarm guard on her left ankle. Interview on 05/31/24 at 2:42 PM with the DON revealed Resident #31 was in the secured unit and was Page 1 of 2 676493 676493 05/31/2024 Sun Valley Rehabilitation and Healthcare Center 2902 S 77 Sunshine Strip Harlingen, TX 78550

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transferred into the general population because she became dependent on Hoyer lift transfers and could no longer be in the secured unit. Resident #31 had an order for an alarm guard on 05/07/24 when she was transferred out of the secured unit. As part of an IDT decision, the order for an alarm guard was requested. Interview on 05/31/24 at 10:55 AM with MDS Coordinator E, revealed Resident #31's care plan was not immediately updated to reflect the use of an alarm guard on 05/07/24 until a significant change status MDS was completed on 05/29/24. MDS Coordinator E said she did not remember she was informed about the order until she completed the significant change status MDS that involved an assessment of the resident's care plans. MDS Coordinator E said she developed a care plan to address Resident #31's use of alarm guard until 05/29/24. Interview on 05/31/24 at 1:34 PM with LVN F revealed a care plan was used to gather information on focus areas, goals and interventions. This information was then communicated to the CNAs 676493 Page 2 of 2