Inspection·October 17, 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, interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans: The facility failed to ensure Resident #1's care plan reflected that he ate quickly and was known to put large amounts of food in his mouth. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: Record Review of Resident #1's admission record, dated 10/17/24, revealed an [AGE] year-old male originally admitted on [DATE] and with diagnoses including dementia with mood disorder, weakness, dysphagia oropharyngeal phase (Patients with oropharyngeal dysphagia have difficulty transferring food from the mouth into the pharynx and esophagus to initiate the involuntary swallowing process), need for assistance with personal care, and muscle wasting and atrophy, not elsewhere classified. Record Review of Resident #1's quarterly MDS assessment, dated 10/06/24, reflected Resident #1 was severely impaired for daily decision making. The MDS showed the resident had a mechanically altered diet. Record review of Resident #1's care plan contained that Resident #1 had a swallowing problem related to swallowing difficulty and actual choking episode initiated on 4/7/24 with interventions to follow prescribed diet, monitor/document/report as needed any signs of symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals, refer to speech therapist for swallowing evaluation, and resident to eat with supervision only. Also, Resident #1 was at risk for impaired nutritional problem due to diet restrictions and malnutrition, no salt added diet, pureed texture, honey thickened liquids consistency, large portions for all meals, initiated on 9/20/23 and revised on 8/28/24. Interventions included explain and reinforce to the resident the importance of maintaining the diet ordered encourage the resident to comply, explain consequences of refusal, obesity/malnutrition risk factors and provide, serve diet as ordered, monitor intake and record every meal. The care plan did not contain any information or interventions related to the resident's behavior of eating fast. (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 4 Event ID: 675159 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 675159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrooke Manor Nursing and Rehabilitation Cente 1401 W Main St Edna, TX 77957 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)