Health inspection·December 4, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #1) reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #1's weight was recorded daily as ordered from 11/22/24 through 12/02/24. This failure could place residents at risk of not receiving care to maintain optimum health and placing them at risk for decline in health. Findings included: Review of Resident #1's face undated face sheet reflected he was admitted on [DATE] and discharged on 12/02/24. Review of Resident #1's admission MDS assessment, dated 11/22/24, Section A (Identification Information) reflected a [AGE] year-old male admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including atrial fibrillation (an irregular heartbeat), heart failure, hypertension (high blood pressure), cirrhosis (severe liver damage), morbid obesity, and diabetes mellitus (a condition that affects the way the body processes blood sugar). Section C (Cognitive Patterns) reflected a BIMS score of 14 indicating intact cognition. Review of Resident #1's care plan initiated on 09/20/24 reflected in part, Resident #1 is at risk for nutritional and/or dehydration risk related to diabetes, congestive heart failure, and morbid obesity. Will maintain nutritional status as evidenced by no significant weight changes through next review. Interventions included, Monitor weights, skin report, and labs . Review of Resident #1's physicians orders dated 11/20/24 reflected, Daily weight once a day 6:00 AM to 11:00 AM. Review of Resident #1's recorded weights reflected 11/19/24 441.5 lbs., 11/20/24 440.5 lbs., and 11/21/24 440 lbs. There were no weights recorded for 11/22/24 through 12/02/24 (11 days). During an interview on 12/04/24 at 12:05 PM, the NP stated it was important to monitor Resident #1's weight because of his heart conditions , chronic edema, and morbid obesity. She stated weight changes could indicate a change in status. Page 1 of 2 455497 455497 12/04/2024 Creekside Terrace Rehabilitation 1555 Powell Avenue Belton, TX 76513

F 0684 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/04/24 at 3:52 PM, with LVN A, she stated the restorative aide was responsible for weighing residents. She stated weights were monitored to help assess changes in fluid balance or nutritional status. She stated Resident #1 had an order for daily weights, but she saw only three weights recorded in the record. She stated she did not weigh the resident and did not know if the resident had refused to be weighed. Residents Affected - Few During an interview on 12/04/24 at 3:57 PM the ADON, stated the restorative aide was responsible for daily and weekly weights but anyone could weigh the residents. There were other staff who were responsible for weights when the restorative aide was not in the building. She stated the weights were included on a weekly report that went to the management team and the weights were reviewed at a meeting. She stated changes in weight could indicate fluid imbalance or CHF. During an interview on 12/04/24 at 4:34 PM, the DON stated the restorative aide was responsible to take and record the weights, but all nursing staff could have taken a weight. She stated the restorative aide was out of the facility, but she had left a message and requested a return call. She stated she found some papers on the restorative aide's desk which included a weight for Resident #1 on 11/26/24. The DON stated the weight was not recorded in Resident #1's electronic medical record. The DON stated it was her expectation that physician orders be followed. During an interview on 12/04/24 at 4:38 PM, the ADM stated it was her expectation that physician orders be followed. Review of the facility policy, Weighing the Resident, revised 02/26/24, reflected in part, Record all weights per facility protocol. The policy did not address daily weights. Review of the facility policy, Physician Orders, revised 05/05/23, reflected in part, 3. Upon admission, the Facility has physician orders for the resident's immediate care to include but not limited to: C. Routine care orders to maintain or improve the resident's functional abilities . 455497 Page 2 of 2