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 (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: 675365 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 675365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pasadena Post Acute 4006 Vista Rd Pasadena, TX 77504 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)