Health inspection·October 2, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 resident (Resident #1) of 8 residents reviewed for care plan accuracy. The facility failed to ensure Resident #1's care plan was updated to reflect a diabetic foot ulcer and treatment. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings include: Record review of Resident #1's undated face sheet printed 09/30/23 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes(condition in the way the body regulates and uses sugar as a fuel), chronic kidney disease stage 3(loss of function in the kidneys), osteoarthritis(wear down of protective tissue), and hyperlipidemia(excess fat in the blood). Record review of Resident #1's undated care plan reflected that Resident #1 did not have a care plan for wound care treatment. Record review of Resident #1's MDS dated [DATE] revealed in Section M skin conditions that Resident #1's foot problem indicated a diabetic foot ulcer. Section C revealed a BIMS score of 14 which indicated cognitive intactness. Record review of Resident #1's physician order dated 08/31/23 revealed apply betadine(antiseptic for minor wounds) to diabetic wound to left dorsal first toe daily. Every day shift for wound care. Physician order dated 08/29/23 revealed apply skin prep to discoloration to left heel/planter daily. Every day shift for wound healing. Physician order dated 09/20/23 revealed clean left heel open area with NS(normal saline)pat dry. Apply collagen powder and Xeroform gauze(antibiotic dressing). Cover with dry dressing every day shift for wound care. Physician order dated 09/20/23 revealed clean right heel open blister with NS(normal saline). Pat dry apply collagen powder and Xeroform gauze(antibiotic dressing). Cover with dry dressing every day shift for wound care. In an interview with the Administrator on 09/30/23 at 3:00 PM, stated that the care plan did not reflect wound care treatment for Resident #1. The Administrator stated she could not state why the care plan was not reflected in the wound care. The administrator stated the DON would have been Page 1 of 2 455503 455503 10/02/2023 Rosewood Heights 5700 E Central Texas Expwy Killeen, TX 76543

F 0657 Level of Harm - Minimal harm or potential for actual harm responsible for care plans because the MDS Coordinator had just taken on the duties and was being trained. The Administrator stated that the MDS Coordinator would have been the one to make sure the care of plan was in place, but the MDS Coordinator was being trained for the job. The Administrator could not give an explanation as to why the DON did not update the care plan. The Administrator stated the DON was no longer employed at the facility as of 09/25/23 for a no-call no-show. Residents Affected - Few In an interview with the DON on 10/02/23 at 11:15 AM, stated that she no longer works at the facility as of 9/25/23. The DON stated she would have been the one responsible to update care plans. The facility was training an MDS Coordinator for the job duty, but she was on vacation when Resident # 1 was admitted to the facility. The DON stated Resident # 1 was admitted to the facility on [DATE] and she was on vacation from 8/16/23 through 8/20/23. The DON stated it was the new MDS Coordinator's responsibility since she was on vacation during the time Resident # 1 was admitted to the facility. In an interview with the MDS Coordinator on 10/02/23 at 3:44 PM, stated that she started training at the end of July and she was still getting training around the time Resident #1 was admitted . The MDS Coordinator stated during her time training it was the DON's responsibility to check the care plan and sign off on it. The MDS Coordinator stated, She wasn't going to lie she just made a mistake and failed to check the care plan and should have checked with the DON not being in the facility'. Review of the facility's job description of MDS Coordinator LVN undated revealed: The MDS Coordinator will assist the DON with ensuring that documentation in the center meets federal, state, and certification guidelines. The MDS Coordinator will coordinate with the RAI process assuring the timeliness and completeness of the MDS, CAAS, and Interdisciplinary Care Plan. Review of the facility 's comprehensive Resident Care plan policy undated revealed: A comprehensive person-centered care plan is developed for each resident using the results of the comprehensive assessment. Each resident's care plan shall include measurable objectives and timetables to meet all resident's needs identified in the comprehensive assessment. All items or services ordered to be provided or withheld shall be included in each resident's plan of care. The comprehensive care plan describes services furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. Resident's right to refuse care and treatment shall also be included in the comprehensive care plan. Each resident's plan of care shall be reviewed by an interdisciplinary team after each MDS assessment is conducted and revised as necessary to reflect the resident's current care needs. Resident's care plans are reviewed at least quarterly. The resident can request a care plan meeting; and participate in setting goals and outcome of care regarding type, amount, frequency, and duration of care; receive the services in the plan of care: see the car plan: request revisions: and sign after significant changes. 455503 Page 2 of 2