Health inspection·September 8, 2022

F 0655 Level of Harm - Potential for minimal harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for 1 of 3 (Resident #86's) resident reviewed for baseline care plans. Resident #86's did not have a baseline care plan This failure placed new residents at risk for continuity of care and adverse events that are most likely to occur right after admission. Findings included: Record review of Resident #86's Facesheet dated 9/8/22 revealed an [AGE] year-old female with an admission date of 8/27/22. Her diagnosis list included Atrial Fibrillation, Altered Mental Status, Dementia, NSTEMI, HTN, Dysphagia, Cognitive Communication Deficits, Unsteadiness on Feet. Record review of Resident #86's Physician Orders dated 9/1/22-9/30/22 revealed: Amiodarone, ASA, Diltiazem, Temazepam, Potassium Chloride, PT Eval And Treatment, OT Eval And Treatment, and a Regular Diet. Record review of Resident #86's Nursing admission assessment dated [DATE] revealed: Atrial Fibrillation, HTN, UTI within last 30 days, Hyperkalemia. Impaired short-term memory modified independent decision making meaning some difficulty in new situations. Wears glasses. Use of antipsychotic medication. Use of a walking device, lower extremity knee impairment both sides. Full set of dentures. Continent of bowel and bladder. Record review of Resident #86's Care plan dated 9/6/22 revealed no care areas with goals and/or interventions began prior to 9/6/22 except Activities that began 8/31/22. During an interview on 9/8/22 at 8:58AM with RN-A, she said the ADON did the baseline care plan based off of the admission assessment the nurses completed. She said it was a specific form that was labeled Baseline Care Plan. RN-A said it should be completed within 48 hours of admission and included any types of medications, diet, ADL care needs, therapies such as OT and PT, as well as activities. During an interview on 9/8/22 at 9:30AM with ADON, she said she had looked through Resident #86's's file and could not find the form for the base line care plan. She said the resident had been admitted to the facility on a Saturday (8/27/22) and that she had worked on the floor as a nurse on Friday (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 3 Event ID: 675279 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 675279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Haven Health and Rehabilitation Center 300 S Jackson St Breckenridge, TX 76424 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)