Health inspection·December 20, 2025

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 record review and interview, the facility failed to develop a baseline care plan that included the instructions needed to provide effective and person-centered care of the residents, for one (Resident #1) of five residents reviewed for base line care plans for newly admitted residents. 1) The facility did not develop a baseline care plan that addressed Resident #1's diabetes mellitus when he was admitted on [DATE]. This failure could place residents at risk of not having their needs met and increase the risk of adverse events regarding diabetes mellitus exacerbation or complications. The findings included: Record review of Resident #1's admission record dated 12/19/2025 revealed Resident #1 was initially admitted on [DATE] and readmitted [DATE]. Resident #1 discharged home with home health services on 09/22/2025. Resident #1 was admitted to the facility with multiple diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, and heart disease. Record review of Resident #1's discharge MDS dated [DATE] revealed Resident #1 had a BIMS score of 12-Moderate cognition impairment and needed partial/moderate assistance with ADLs and was coded for type 2 diabetes with diabetic peripheral angiopathy without gangrene (narrowing of arteries in the legs due to diabetes but without tissue death). Record review of Resident #1's NURSING: Baseline Care Plan assessment admission date 09/18/2025 revealed #18 was not check marked for Resident has Diabetes Mellitus. Record review of Resident #1's Care Plan Report date initiated 09/18/2025 revealed it did not include a care plan for diabetes mellitus. During an interview on 12/19/2025 at 3:37PM the MDS Coordinator stated while she reviewed the baseline care plan assessment, box number 18 was not checked marked. The MDS Coordinator stated number 18 was entitled resident has diabetes mellitus. The MDS Coordinator stated if Resident #1 had diabetes mellitus the baseline care plan would be reflective of the admitting diagnosis. The MDS Coordinator stated Resident #1 was admitted to the facility on [DATE] for respite care and discharged on 09/22/2025. The MDS Coordinator stated LVN A failed to check mark number 18 by mistake. The MDS Coordinator stated there was no negative outcome due to Resident #1's baseline care plan lacking his admitting diagnosis of diabetes mellitus. The MDS Coordinator stated while she reviewed Resident #1's baseline care line, Resident #1's diagnosis of diabetes mellitus should have been within his baseline care plan. The MDS Coordinator stated baseline care plans are important because they outline the individualized plan of care, but reiterated there was no negative outcome from the missed baseline care assessment of diabetes mellitus for Resident #1. The MDS Coordinator stated the usual procedure for admission/readmissions begins when the admitting nurse facilitates the admission baseline care plan assessment, which will then be reviewed by the RN which used to be the previous DON. The MDS Coordinator stated that going forward she will be more diligent while reviewing baseline care plans as well as comprehensive care plans. During an interview on 12/20/2025 at 10:32AM LVN A stated Resident #1 was admitted on [DATE] for a 5-day respite stay. LVN A stated she was Resident #1's admitting nurse and recalled Resident #1 had diabetes mellitus. LVN A stated while Page 1 of 2 455687 455687 12/20/2025 Alameda Oaks Nursing Center 1101 S Alameda Corpus Christi, TX 78404

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewing Resident #1's baseline care plan assessment, dated 09/18/2025, she had forgotten to click the resident has diabetes mellitus box, and since she did not check mark the box on the admission assessment, the baseline care plan did not populate interventions/care plan for diabetes mellitus. LVN A stated Resident #1 never suffered any negative outcomes due to the missed diabetes mellitus diagnosis on the baseline care plan. LVN A stated she recalled Resident #1 received oral antidiabetic medication. LVN A stated she followed Resident #1's physician orders, and completed glucose monitoring, and oral antidiabetic medication administration. LVN A stated the procedure for facilitating a baseline care plan commences when the admission nurse populates a care plan assessment. Once the care plan assessment was completed, an RN would review the assessment and sign off that the assessment was accurate and addresses the admitting diagnoses. Once the RN signed off, a baseline care plan would then be populated within Resident #1's electronic health record. LVN A stated lastly, the MDS Coordinator would review the baseline care plan as a third review. LVN A stated she accidentally missed clicking the resident has diabetes mellitus box. LVN A stated she should have clicked that specific box, but did not, and therefore affected the accuracy of Resident #1's baseline care plan. However, LVN A stated there were no negative outcomes for the missed check mark. LVN A stated baseline care plans are important as they reflect the individualized plan of care for Resident #1. LVN A stated going forward she will be more diligent in clicking the admission assessment boxes to ensure the baseline care plans are accurate. During an interview on 12/20/2025 at 11:34AM the Interim DON stated she became the interim DON in November 2025 and could not speak to the actions of the previous DON. The interim DON stated that going forward all admissions/readmissions would thoroughly be reviewed during the daily morning meetings, as well as being reviewed by not only herself but also the MDS Coordinator to ensure accuracy. Additionally, the facility would facilitate an impromptu in-service regarding care plan assessments, and baseline care plans. The interim DON stated while she reviewed Resident #1's electronic health care record as well as through her staff interviews, Resident #1 had no negative outcome due to the mistake of LVN A. The interim DON stated a diagnosis of diabetes mellitus would be within a baseline care plan. The interim DON stated baseline care plans were important, as they were individualized plans of care of what the facility was doing to mitigate any potential exacerbation of disease processes. Attempted to phone interview with the previous DON on 12/19/2025 at 4:58PM, 12/20/20/2025 at 10:30AM, 11:46AM but they did not return call by the exit conference. Record review of the facility's Area of focus: Care Planning-Baseline, Comprehensive , and routine updates Baseline care plan issued: 01/04/2022 and reviewed: 12/04/2025 revealed, Baseline care plan: Completion and implementation of the baseline care plan within 48 hours of the resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard again adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services. 455687 Page 2 of 2