Health inspection·October 6, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for 2 of 18 residents reviewed for care plan accuracy (Residents # 6, # 46). The facility failed to revise comprehensive care plans to reflect the reevaluation of visitation recommended by CMS for Residents # 6 and # 46 This failure placed residents at risk of not having their needs met and social isolation which could lead to a diminished quality of life. Findings include: Resident # 6 Record review of the face sheet for Resident # 6 revealed a [AGE] year-old female, admission date of 11/24/20, with diagnoses including schizoaffective disorder, epilepsy, anxiety disorder, pain, spinal stenosis (narrowing of the spinal canal) and bipolar disorder. Record review of Resident # 6's quarterly MDS dated [DATE] revealed a BIMS Summary score of 13, indicating intact cognition in cognitive skills for daily decision making, usually understood and usually understands, limited to extensive assistance required for Activities of Daily Living and incontinent of bladder and bowel. Record review of Resident # 6's comprehensive care plan, initiated and revised 1/8/21, revealed the resident had restricted visitation secondary to COVID-19 precautions, with interventions including providing alternative methods of communicating with family and friends. Observation of Resident # 6 on 10/4/22 at 1:25 p.m. revealed she was in her wheelchair in her room, watching TV. Interview at that time revealed she was fine, and she could have visitors now that the virus had cleared up. Resident # 46 Record review of Resident # 46's face sheet on 10/5/22 revealed a [AGE] year-old male, admission date of 12/12/18, with diagnoses including cerebral infarction (stroke), hypertension, convulsions, major depressive disorder, anxiety disorder, hemiplegia (paralysis on one side of the body), and Page 1 of 2 675365 675365 10/06/2022 Pasadena Post Acute 4006 Vista Rd Pasadena, TX 77504

F 0656 speech disturbances. Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 46's quarterly MDS dated [DATE] revealed a BIMS Summary score of 10, indicating moderately impaired cognitive skills for daily decision making, usually understood and usually understands, extensive to total assistance required for activities of Daily Living, and incontinent of bowel and bladder. Residents Affected - Some Record review of Resident # 46's care plan, initiated 3/17/20 and revised 3/17/20, revealed restricted visitation secondary to COVID-19 precautions with intervention including to provide alternative method of communicating with family and friends. Observation of Resident # 46 on 10/4/22 at 10:10 a.m. revealed he was in bed, alert and oriented, and did not speak due to a healing stoma (a surgical opening in the neck for a tracheostomy (a tube to assist with breathing). He was able to make his needs known and nodded his head when asked if he could have visitors. Interview with the DON on 10/6/22 at 9:40 a.m. revealed there were no visitor restrictions for COVID-19 in the building currently. The DON said the care plans needed to be revised to remove the visitor restriction for COVID-19 since they could accept all visitors according to CMS guidelines. She said the care plans should have all been revised when CMS lifted the visitor restriction. The DON stated the previous MDS Coordinator left last week, and she had missed creating and updating a lot of care plans, so an MDS Nurse who worked here before had come back this week to help with the care plans since they needed to be accurate for the resident's care. Interview with the Infection Preventionist on 10/6/22 at 9:55 a.m. revealed there were no visitor restrictions in the facility due to COVID-19. Record review of the COVID-19 Response for Nursing Facilities dated 6/27/22 revealed, in part: .the latest guidance on visitation .is now allowed for all residents at all times, per CMS. A facility policy on care plans was not available by the time of exit. 675365 Page 2 of 2