Health inspection·July 22, 2025

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 interview and record review, the facility failed to ensure the comprehensive care plan was developed and implemented within a timely manner for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #1) out of 5 residents reviewed for care plans. The facility failed to update or revise Resident #1's care plan to reflect Resident #1's verbal and combative behavior of resistant to care or refusal of care. This failure could place resident at risk for receiving inadequate care and services. Findings included:Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old female with an admission date of [DATE]. Diagnoses included Alzheimer's with Late Onset (a chronic condition which primarily affects memory, thinking, and behavior), Dementia (decline in cognitive function which affects daily life, memory, reasoning, and language skills), Cognitive Communication Deficit (difficulties in communication which arise from impaired cognitive functions, such as attention, memory, reasoning, and problem-solving), and Need for Assistance with Personal Care.Record review of Resident #1's quarterly MDS assessment, dated [DATE], revealed BIMS was not conducted as Resident #1 was rarely or never understood. The language section of the MDS revealed the preferred language was Vietnamese, and MDS was unable to determine if an interpreter was needed to communicate with a doctor or health care staff.Record review of Resident #1's current care plan initiated [DATE] and revised [DATE] revealed a care plan for resident resistive to care related to dementia, Resident #1 yelled at staff during incontinent care and refused to allow staff to shower her, obtain vitals, or weigh her. Care plan goal initiated [DATE] revealed Resident #1 would cooperate with care through next review. Care Plan interventions initiated [DATE] revealed: allow resident to make decisions about treatment, encourage participation, and if resident resists ADLs, reassure her, leave and return 5-10 minutes later to try again. Goals and Interventions were added[DATE]. Care plan also revealed Resident #1 had a communication problem related to a language barrier, initiated [DATE], and revised [DATE]. Interventions for communication problem care plan, initiated [DATE], included anticipate and meet Resident #1's needs, Resident #1 preferred to communicate in Vietnamese, and Resident #1 required communication cue cards located in nightstand.Record review of Resident #1's progress note dated [DATE] revealed RN-A was called to Resident #1's room by the CNA, who had reported Resident #1 had slid off bed after incontinent care. Resident #1 was noted to be on the floor on the left side of her bed, lying on her left side with her sheet wrapped around her. Resident #1 was alert and yelling in Vietnamese, as well as moving her arms and legs. CNA attempted to use an electronic translator to attempt to interview resident, but translator was unable to produce a response. No visible injuries were noted, skin assessment performed, and Resident #1 was assisted by 2 staff back into bed, and incontinent care was provided. Resident refused to allow blood pressure or oxygen to be taken, but pulse was 74 and respirations Page 1 of 3 455974 455974 07/22/2025 Rockport Nursing and Rehabilitation Center 1902 Fm 3036 Rockport, TX 78382

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were 18. Record review of Resident #1's Kardex (a quick reference or an extension of the care plan, derived from the care plan, used by CNAs and other staff to stay updated on residents key needs and care) dated [DATE] revealed a communication section with interventions to include: ask yes or no questions to determine resident's needs, Resident #1 prefers to communicate in Vietnamese, Resident #1 required communication cue cards which were located in the bedside table and ensure availability and functioning of adaptive communication equipment. In an interview on [DATE] at 10:05 AM, CNA-B stated Resident #1 spoke Vietnamese, so she could not understand her, but she would smile in response when spoken to like she understood some things which were said to her in English, but other than this, the staff had no way to formally communicate with this resident or understand what Resident #1 was saying to them or needing from them. CNA-B stated Resident #1 would get worked up frequently and yell, but she had never seen her get combative. CNA-B stated she walked into Resident #1's room on [DATE] after Resident had fallen out of bed. She stated she had offered assistance with the resident since she had showered her earlier in the day and had a good rapport with her. She stated Resident #1 was talking and yelling in Vietnamese but was not crying or grimacing like she was in pain. She stated she had no other way to communicate with her or understand her, as CNA-C had already tried the translator device, and it had not worked. It was not typically used for this resident as it would not pick up what she was saying or yelling. She did say she could answer some simple yes or no questions if they point to things and asked, such as pointing to or rubbing stomach and asking if it hurt. In an interview on [DATE] at 10:39 AM, CNA-C stated after Resident #1 fell out of bed on [DATE], she was being combative and yelling and speaking in Vietnamese, but she could not understand what Resident #1 was saying. CNA-C stated she and RN-A tried to use the translator to understand Resident #1, but it was not picking up or understanding what the resident was saying. She also stated Resident #1 yells frequently, which was typical for her. She stated she had no other way to formally communicate with Resident #1 to find out what she was saying or what she needed, but she would shake her head yes or no to simple questions such as pain.In an interview on [DATE] at 11:09 AM the ADON stated it was either her or the MDS nurse which typically updated the clinical care plans. She stated at some point in time between the previous care plan which was initiated [DATE] and the current care plan, which was initiated [DATE], there was a behavior problem listed, but it must have dropped off, been deleted, or gotten closed out, and this was why there was a new problem for resistive to care added on [DATE]. She stated she was not sure why the goals and interventions were not added to the care plan until [DATE], the day Resident #1 expired, and she also stated she did not remember if it was herself or the MDS nurse who had added them. The ADON stated Resident #1 had always been combative and verbally aggressive with incontinent care and ADLs, and it was something which should have always been care planned, so it dropping off or being removed was by mistake. She stated Resident #1 was able to nod in response or say simple phrases like thank you, but she did have the cue cards at bedside to assist with communication. She stated the CNAs utilized the Kardex, which was derived from the care plan, to learn and know more about the residents they were caring for, and Resident #1's language preferences were on the care plan and the Kardex. She stated if a CNA did not typically work the hall of a resident, then they may not have known the cue cards were in the bedside table. She stated the CNAs should have been looking at the Kardex, but many times they may have only skimmed it for the highlights such as transfer and mobility status. She stated she felt like maybe the CNAs needed more training on what the Kardex was and how it was used. In an interview on [DATE] at 1:17 PM, the MDS Nurse stated she hadn't really started working on care plans because she was new and just started this job and was still training. She also stated Resident #1's MDS assessment and care plan probably 455974 Page 2 of 3 455974 07/22/2025 Rockport Nursing and Rehabilitation Center 1902 Fm 3036 Rockport, TX 78382

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were not the best due to the language barrier with Resident #1, and she was not able to ask Resident #1 any questions, so she mostly asked staff which took care of her on a daily basis regarding the MDS questions. She also stated she was not able to consult with family as Resident #1 did not have any family, and the only contact was a friend who never returned phone calls or came to care plan meetings or to visit Resident #1. The MDS nurse stated the care plan problem resistive to care or refuses care was care planned previously, and she wasn't sure why it was ever removed or dropped off; she also was not sure why the current care plan was initiated [DATE], but the goals and interventions were not initiated until [DATE]. In an interview on [DATE] at 2:31 PM, CNA-B stated she knew what a Kardex was because she learned about it in her CNA program, and she knew she was supposed to be reviewing it and using it, but she admitted the Kardex rarely got used, and she had not reviewed it for Resident #1. She stated she had not known there were cue cards in Resident #1's bedside table. CNA-B also stated she had never had an in-service or training in this facility regarding the use of the Kardex. She stated if she and the other staff had reviewed the Kardex, they would have known there were cue cards in the bedside table, and they may have been able to better communicate with Resident #1 and understand what she was yelling about. Record review of the facility's Comprehensive Care Plan Policy, dated [DATE], revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs which were identified in the resident's comprehensive assessment. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. 455974 Page 3 of 3