Health inspection·August 5, 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 observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan 7 days after each comprehensive assessment and no more than 21 days after admission for 2 of 5 residents (Residents #1 and Resident #2) reviewed for care plan revision and timing. 1. The facility failed to updated Resident #1's care plan to reflect Resident #1's foley catheter was removed in 2023. 2. The facility failed to implement a comprehensive care plan for Resident #2. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. Findings include: Review of Resident #1 face sheet reflected an [AGE] year-old man admitted on [DATE] with diagnoses of unspecified dementia (group of symptoms affecting memory, thinking, and social abilities), depression (mood disorder that causes persistent feelings of sadness and loss of interest in activities), dysphagia (difficulty swallowing), and type 2 diabetes (chronic condition where the body doesn't properly use insulin to regulate blood sugar). Review of Resident #1's care plan dated 09/27/2023 reflected Resident #1 had an indwelling foley catheter. Goal included catheter would be removed, when possible, over next 90 days with target date of 11/25/2025. Further review of care plan dated 09/26/2023 reflected Resident #1 was a new admission to SNF with goal to adjust to facility with target date of 11/25/2025. Review reflected Resident #1 had impaired cognitive function and required 1:1 staff assistance with toileting and hygiene. Review of Resident #1's orders reflected an order for catheter care every shift was discontinued on 10/02/2023. Review of Resident #1's NP progress note dated 10/05/2023 reflected foley catheter was discontinued. Review of Resident #1's quarterly MDS dated [DATE] reflected Resident #1's BIMS was not conducted as he was rarely or never understood. Review of MDS section H reflected none of the above was selected for bowel and bladder appliances. Indwelling catheter was not selected. Review of Resident #1's orders reflected an order for catheter care every shift was discontinued on 10/02/2023. Review of Resident #1's NP progress note dated 10/05/2023 reflected foley catheter was discontinued. Observation and attempted interview on 08/04/2025 at 11:16 AM revealed Resident #1 sat in the dining room with no foley bag observed on his wheelchair or leg. Resident #1 was unable to answer questions and mumbled as residents approached him. Review of Resident #2's face sheet reflected a [AGE] year-old man admitted on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage in brain stem (stroke where bleeding occurs within the brain stem), malignant neoplasm of prostate (prostate cancer), alcoholic cirrhosis of liver (breakdown of the liver due to alcohol use) and type 2 diabetes (chronic condition where the body does not properly use insulin to regulate blood sugar). Review of Resident #2 quarterly MDS dated [DATE] reflected a BIMS score of 11 which indicated a moderate cognitive impairment. Review of Resident #2's baseline care plan reflected a date of 05/24/2025. Review reflected Resident #2 was always incontinent of bowel and bladder. Review of Resident #2's chart on 08/05/2025 reflected he had no comprehensive care plan created. Page 1 of 2 675118 675118 08/05/2025 Brush Country Nursing and Rehabilitation 6500 Brush Country Rd Austin, TX 78749

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #2 comprehensive care plan should have been created 21 days after admission on [DATE]. During an interview on 08/05/2025 at 3:01 PM, LVN A stated that cares are generated by an RN and include any devices a resident had and had information to care for the resident. During an interview on 08/05/2025 at 3:28 PM, the DON stated that for the comprehensive care plan, each discipline completed their section and stated that wounds were care planned by the wound nurse, antibiotics by the MDS coordinator and room information by the social worker. The DON stated that the MDS coordinator was responsible to start the comprehensive care plan. The DON stated that she expected every resident to have a care plan in place. The DON stated that the importance of the care plan was to monitor any changes and the resident's condition. The DON stated it showed the residents' baseline at admission and evaluates their status quarterly. The DON stated the care plan was updated quarterly. The DON stated that she did not think there was a definitive person that audited that care plans were updated or completed behind the MDS coordinator, but the DON reviewed care plans sporadically. During an interview at 08/05/2025 at 5:17 PM, LVN B stated that a care plan included general needs of the resident, behaviors, ADL needs and bowel and bladder information. LVN B stated that a care plan has the residents needs to be cared for. During observation and interview on 08/05/2025 at 3:47 PM, the MDS coordinator stated that her role for the comprehensive care plan was to open up or create the care plan if the resident was a new admission. The MDS coordinator stated that she updated the care plan with triggers from the MDS. The MDS coordinator stated that the care plan was also a working document and can be updated as things come up such as dietary changes or behaviors. The MDS coordinator stated that at the latest the care plan had to be completed 21 days after admission but could be completed sooner. The MDS coordinator stated that the importance of the care plan was that it was based on assessment and discovered potential problems, situation or things that needed to be addressed. The MDS coordinator was observed viewing Resident #2's care plan and stated there was no care plan in place and was blank. The MDS coordinator stated she was not in the role at that time and started at the facility on 07/07/2025 and had not reviewed all of the care plans. During an interview on 08/05/2025 at 5:22 PM, the ADM stated the purpose of the care plan was to create a plan of care for the resident upon admission through discharge. The ADM stated she expected the comprehensive care plan to be completed within 21 days of admission. The ADM stated that the care plan was updated every 90 days. The ADM stated she expected the catheter or treatment to be discontinued on the care plan when it occurred. The ADM stated each department was responsible for updating the care plan. The ADM stated there was not any process in place to follow up that care plans were updated behind the MDS coordinator, but there was an audit being completed and all care plans were being reviewed. Review of the facility policy titled Care Plans, Comprehensive Person-Centered with revision date of December 2016, reflected the comprehensive person-centered care plan was completed within seven days of the completion of the comprehensive assessment. The policy reflected that the IDT should review and update the care plan where there has been a significant change in the resident's condition. 675118 Page 2 of 2