Health inspection·March 4, 2025

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 for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 10 residents (Resident #1) reviewed for care planning. The facility failed to ensure that Resident #1's care plan addressed the use of an arm immobilizing device. This failure could cause residents to experience a decreased quality of life and reduced mental and psychosocial well-being due to resident's needs not being met. Findings included: Record review of Resident #1's medical chart revealed Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with a BIMS score of 13 (which indicated she was cognitively intact) and a primary diagnosis of Spastic Quadriplegic Cerebral Palsy. (Spastic Quadriplegia is the most severe form of Cerebral Palsy, affecting both arms and legs. People with this type of quadriplegia often cannot walk and have very limited use of their arms.). Resident #1's MDS dated [DATE] reflected the need for full asstance with dressing, a 1-2 person assist with both transfer and toileting and the need for set-up and weighted silverware while eating. Record Review of Resident #1's Physician's orders revealed there was no order for the arm immobilizer, nor was the immobilizer part of Resident #1's Care Plan. On 03/04/2025 at 11:30AM an observation of and interview with Resident #1 was conducted. Resident #1 was observed to be wearing an immobilizer on her right arm, which kept her arm close to her body and across the front of her chest. Resident #1 stated she had not hurt her arm in any way but had Cerebral Palsy. She stated she would require help from staff to remove the immobilizer from her arm. In an interview on 03/04/2025 at 11:39AM the DON stated the order for the immobilizer had possibly been archived and she would print a copy of both the order and the Care Plan for my review. On 03/04/2025 at 12:33PM the DON stated there was no order for the immobilizer and it had not been addressed in Resident #1's Care Plan. She stated she believed the immobilizer was placed by an unknown Physical Therapist, sometime last summer and staff removed it every night before Resident #1 went Page 1 of 3 675498 675498 03/04/2025 Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to bed. She stated the negative outcome of not having an order and Care Plan for the immobilizer would have been new staff would not know to remove the immobilizer at night and it might cause Resident #1 to develop a pressure injury. The DON stated the negative outcome of not wearing the immobilizer during the day would have been Resident #1's spastic arm might have hit a doorway as she was ambulating. The DON ensured the order had been obtained from the doctor and the Care Plan had been updated. She was unsure why there had not been an order for the immobilizer previously, nor why the immobilizer had not been addressed in Resident #1's MDS or Care Plan. Record Review of Resident #1's orders and progress notes reflected she had not received PT since admission, so it was unclear how the immobilizer was placed by a Physical Therapist. Facility policy and procedure for Care Plan Process, Person-Centered Care stated the following: A. The facility will develop and implement a baseline and comprehensive Care Plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet the professional standards of quality care. Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes trying to understand what each resident is communicating, verbally and non-verbally, identifying what is important to each resident with regard to daily routines and preferred activities, and understanding the resident's life before coming to the nursing home. The services provided or arranged by the facility, as outlined by the comprehensive person-centered Care Plan, will meet professional standards of quality. The person-centered Care Plan includes: A. Date B. Problem C. Resident goals for admission and desired outcomes D. Time frames for achievement E. Interventions, discipline specific services, and frequency 675498 Page 2 of 3 675498 03/04/2025 Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119

F 0656 F. Level of Harm - Minimal harm or potential for actual harm Refusal of services and/or treatments 1) Residents Affected - Few Evaluation of resident's decision-making capacity 2) Educational attempts 3) Attempts to find alternative means to address the identified risk/need. G. Discharge Plans 1) Resident's preference and potential for future discharge 2) Resident's desire to return to the community and any referrals to local contact agencies and/or other appropriate entities, for this purpose H. Resolution/Goal Analysis 675498 Page 3 of 3