Health inspection·September 9, 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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents reviewed for care plans. (Resident #1) The facility failed to develop and implement the comprehensive person-centered care plan for Resident #1 by not documenting foley catheter changes. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings include: Record review of a face sheet dated 11/7/22 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including Obstructive and Reflux Uropathy (A blockage in the urinary tract that prevents urine from flowing normally. This can cause urine to back up into the kidneys, which can damage them.), COPD (Chronic obstructive pulmonary disease is a chronic lung disease that makes it difficult to breathe), Benign Prostatic Hyperplasia with lower Urinary Tract Symptoms (Benign prostatic hyperplasia (BPH) is a condition that occurs when the prostate grows and compresses the bladder and urethra, causing lower urinary tract symptoms). Record review of the Quarterly MDS dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated a BIMS of 12 indicating moderate cognitive impairment. The MDS indicated Resident #1 used a foley catheter. Record review of physician's orders for Resident #1 dated 08/6/24 indicated an order for Foley Catheter and Drainage Bag - change q month and PRN every night shift starting on the 14th and ending on the 15th every month related to OBSTRUCTIVE AND REFLUX UROPATHY, UNSPECIFIED (N13.9) AND as needed. Record review of a care plan dated 09/09/24 indicated Resident #1 had a problem with toilet use due to an ADL self-care deficit. TOILET USE: Resident #1 is incontinent of bowel. Has a supra-pubic foley (medical device that helps drain urine from your bladder) for bladder CNA elimination. Requires staff assist for clothing and cleansing. Toilet hygiene: dependent. Care plan did not indicate how often to change Resident #1's catheter. Record review of Resident #1's electronic health records, progress notes, revealed no indication that Resident #1's catheter had been changed from 1/1/2024 to 9/5/2024. (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: 675133 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 675133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601 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)