Health inspection·March 7, 2024

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 observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive person-centered care plans. The facility failed to develop and implement a care plan for Resident #1's wound care to the left breast. This failure could place residents at risk of not having individual needs met and a decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 03/07/2024, revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy (a problem in the brain caused by chemical imbalance in the blood), Cellulitis of Left Lower Limb (a serious bacterial infection of the skin in the leg), Type 2 Diabetes Mellitus without complications (a chronic condition that affects how the body processes blood sugars), Bipolar (a mental disorder characterized by periods of depression and periods of abnormal elevated mood), Chronic Obstructive Pulmonary (a group of lung diseases that block airflow and make it difficult to breath), Atherosclerotic Heart Disease (the buildup of fats, cholesterol and other substances on the artery walls), Gastro-Esophageal Reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of the MDS quarterly assessment dated [DATE] indicated Resident #1 was able to make self-understood and understood others. The MDS assessment indicated Resident #1 had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS assessment Indicated Resident #1 required extensive assistance with two-person assistance for bed mobility, transfers (Hoyer lift), toilet use, dressing and personal hygiene. The MDS assessment did not indicate Resident #1 had wounds or skin condition issues. Record review of the comprehensive care plan last revised on 11/01/2023 indicated Resident #1 had no care plan for wound care to the left breast. Record review of Resident #1's order summary report with a date range of 11/01/2023 - 03/06/2024 Page 1 of 2 675020 675020 03/07/2024 Greenville Health & Rehabilitation Center 4910 Wellington St Greenville, TX 75402

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated cleanse the non-pressure wound of the left breast with normal saline, pat dry, apply over the counter miconazole powder, cover with Calcium Alginate, and cover with border gauze every day, until healed every shift. Record review of Resident #1's progress note dated 11/01/2023 indicated left breast continues with a non-pressure wound related to cellulitis of the breast that has subsided. Wound measured as a cluster 9.5 x 6 x 0.3 cm with beefy red wound bed and a moderate amount of serious exudated. No improvements over the last 7 days. Continue calcium alginate and bordered gauze dressing daily. Record review of Resident #1's physician's wound evaluation management summary dated 11/08/2023 indicated non pressure wound of the left breast due to trauma/injury- full thickness. Wound size 10.5 x 5.5 x 0.2 cm, surface area of 57.76 cm, cluster wound open ulceration with moderate serous exudate. During an interview on 03/07/2024 at 01:00 PM, the MDS Coordinator stated she was responsible to update the care plans quarterly and yearly. The MDS Coordinator stated the ADONs, and DON were responsible for all other updates to the care plans. The MDS Coordinator stated it was important for the plan of care to accurately reflect the resident's needs for proper care. During an interview on 03/07/2024 at 01:32 PM, the DON stated the MDS Coordinator was responsible for ensuring everything for the resident's care was included in the care plans yearly and quarterly. The DON stated she was responsible for the updates for care plans. The DON stated Resident #1 should have had a care plan for wound care services being provided daily. The DON stated she did not know why it was not in the care plan. The DON stated it was important for Resident #1's wound care services to be included in her care plan because it is the map of providing care of the resident and resulted in continuity of care. During an interview on 03/07/2024 at 02:15 PM, the Administrator stated the DON and the MDS Coordinator were responsible for completing the care plans. The Administrator stated she expected them to include in the care plan wound care services and anything unusual or special for the resident's care. The Administrator stated it was important for Resident #1's wound care to be included in the care plan so the staff could ensure the resident was receiving appropriate care. Record review of the Care Plan and Care Area Assessments policy, revised on 05/06/2021, stated This identification and implementation of a plan of care will begin at admission with the initial care plan and be completed throughout assessment process for developing a comprehensive plan of care. The policy further indicated, Acute Care Plans o As acute problems or changes to intervention or goals are identified, an appropriate care plan will be developed or modified by a Nursing staff member. o CMMs are only responsible for care plans that relate to the MDS triggers at the time of assessment completion. 675020 Page 2 of 2