Health inspection·March 20, 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, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing and mental and psychosocial needs for 1 (Resident #1) of 3 residents reviewed for care plans. -The facility failed to ensure Resident #1 's pacemaker was addressed on her care plan. This failure placed the resident at risk for not having their individual needs met in a timely manner and could result in injury and a decline in physical well-being. Findings included. Review of Resident #1 face sheet, dated 03/19/2025, reflected an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of presence of cardiac pacemaker. Review of Resident #1's Quartely MDS assessment, dated 01/22/2025, reflected Resident #1 had a Brief interview for mental status score of 04 indicating severe cognitive impairment. Presence of pacemaker was listed under her diagnoses. Review of Resident # 1's comprehensive Care plan dated 3/1/25 did not reflect anything relating to her pacemaker. Interview with LVN A on 3/19/25 at 1:20 p.m. revealed that the purpose of the care plan was to make anyone aware of changes and details what kind of care the resident needs. She stated that she had not reviewed the care plan for the resident, and she was not aware that her pacemaker was not on the care plan. She stated that she is not a part of care plan meetings, and if there was a change to any resident's care plan, staff is notified via the DON and ADON verbally in meetings and in-services. She stated that she looked at residents' orders to see if anything changed throughout the day. The risk of the pacemaker not being care planned included missed communication and missed potential changes to care. Interview on 3/19/25 at 1:43 p.m. with the DON , revealed that whatever care area was triggered on the MDS would be on the care plan,. She stated if it was not triggered, then it would not show up on the care plan. She stated that nurses had to use their nursing judgment when it came to caring for a resident with a pacemaker. She stated that the nurses would report low pulse to Doctor or NP, monitor for dizziness or fainting. She stated that CNAs do not read care plans, because they did not have the time to do so. She stated that she and ADON would inform them and staff nurses of resident Page 1 of 2 675768 675768 03/20/2025 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0656 care plan, and the care that residents needed. Level of Harm - Minimal harm or potential for actual harm Interview with ADON nurse on 3/19/25 at 2:07 p.m. revealed that the pacemaker was not included in care plan because MDS did not trigger that care area. She stated that Resident #1's pacemaker should have been included in the care plan to ensure continuity of care and prevent the resident going to hospital. She stated that any changes to resident care was verbally told to staff (nurses and CNAs) via meetings and in-services. Residents Affected - Few Review of the facility's policy entitled Care Plans - Comprehensive revised December 2010 read in part, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each resident.The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS . 675768 Page 2 of 2