Health inspection·January 19, 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 interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical and nursing needs for one (Resident #1) of four residents reviewed for care plans, in that: The facility failed to develop a care plan for Resident #1's sacrum (a shield shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) stage four pressure ulcer and the care plan did not address his non-compliance with treatment. This failure could place residents at risk for not having their individual care needs met, errors in providing care, poor wound healing/worsening wound condition. Findings included: Review of Resident #1's Face Sheet dated 1/4/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Adult failure to thrive (older adult has a loss of appetite, eats and drinks less than usual, and is less active than normal), Osteomyelitis of vertebrae (painful bone infection that develops from bacteria or fungi, is itself rare), Chronic Obstructive Pulmonary Disease (chronic condition in which a patient's lungs are susceptible to infections and moreover, the infections show exaggerated symptoms in the patients. Hence there is higher risk of morbidity and mortality in the patients suffering from COPD (as compared to normal people), and chronic respiratory failure (when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). Review of Resident #1's Quarterly MDS dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 13 indicating cognition was intact. Resident #1 was assessed to be dependent on staff for ADL assistance. Resident #1 was assessed to have unhealed pressure ulcer and a wound infection. Resident #1 was on routine pain medications. Review of Resident #1's Comprehensive Care Plan dated from 12/04/2023 to 01/04/2024 reflected a focus area revised on 12/21/2023 Resident #1 had pain. Resident #1 had COPD. Resident #1 was assessed for intolerance related to imbalance between supply oxygenation needs. Resident #1 pressure ulcer to the sacrum was not assessed on the current care plan dated 12/21/2023. Review of Resident #1's Consolidated Physician orders dated from 12/04/2023 to 01/04/2024 reflected an order dated 09/26/2023 reflected daily wound treatment: Stage 3; clean with NS/NC; pat dry: apply skin prep to wound edges; apply honey alginate calcium to wound bed; cover with foam silicone (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675132 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bremond Nursing and Rehabilitation Center 211 N Main Bremond, TX 76629 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)