Health inspection·February 20, 2025

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 ensure each resident / and or their representative were invited to attend/participate attend and IDT in the care plan meeting including both the comprehensive and quarterly review assessments for with the participation of the resident for 1 of 6 residents (Resident's #1) reviewed for care plan timing and revision. The facility failed to ensure representatives/residents were invited to attend comprehensive care meetings for Resident #1. The facility failed to document the reason for the representative/resident non-participation in the care plan meeting. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. The findings included: In a record review of Resident #1's face sheet, dated 02/19/25, revealed the resident was a [AGE] year-old female, originally admitted to the facility on [DATE] and with the latest admission date of 09/19/24. The resident was discharged on 02/10/25 to the local hospital. Resident had diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (blockage of the arteries of the heart), dysphagia (difficulty swallowing), and vascular dementia (brain damage caused from impaired blood flow). In a record review of Resident #1's last quarterly MDS, dated [DATE], revealed resident's BIMS score was 00 reflecting resident was not able to complete the interview and was not interview able. In an interview on 02/20/25 at 10:00 am, Resident #1's POA stated she had not been invited to a care plan meeting in a long time. In a record review of Resident #1's comprehensive care plan revealed it was dated as reviewed/revised on 01/07/25. The attendance document on the care plan was blank. In a record review on 02/20/25 at 11:00 am, Resident #1's progress notes revealed no documentation evidence that the resident had been invited to participate or attend a care plan conference. In an interview on 02/20/25 at 10:45 am, the Social Worker stated the facility reviewed Resident #1 Page 1 of 2 455931 455931 02/20/2025 Advanced Rehabilitation and Healthcare of Vernon 4401 College Dr Vernon, TX 76384

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care on 01/16/25 but never did have an official care plan meeting with Resident #1 or with Resident #1's POA. She said the meeting should have been shortly after the facility review. She said it was her responsibility to arrange care plan meetings. She said she has been out sick, and it was missed. In an interview on 02/20/25 at 1:30 pm, the Administrator said Resident #1's care was reviewed by the facility on 01/16/25 with the facility doctor, Administrator, MDS nurse, and the Business Office Manager in attendance. She said the facility did not have an official care plan meeting that included the resident or the resident's representative. She said the Social Worker had been out sick and it was missed. She said it was her expectation for the facility to invite the resident and resident's representative to the care plan meetings . She said a potential negative outcome would be the resident's family would not know anything about the resident's care plan. Record review of the facility policy Comprehensive Care Plans, dated as reviewed/revised 09/04/24, revealed the following [in part]: Policy: Is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights . Policy Explanation and Compliance Guidelines: d. The resident and the resident's representative, to the extent practicable. 455931 Page 2 of 2