Health inspection·January 30, 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights for 1 of 5 (Resident #1) residents reviewed for care plans, The facility failed to ensure Resident #1's code status was properly care planned. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. 1. Record review of the face sheet dated 1/30/25 indicated Resident #1 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's, heart failure, and hypertension (elevated blood pressure). Record review of the physician orders dated 1/30/25 for physician orders active as of 1/3/25 indicated Resident #1 had an order for Code Status: DNR starting 6/4/24. Record review of an Out-Of-Hospital Do-Not-Resuscitate Order dated 6/4/24 indicated Resident #1 DNR was effective 6/4/24. Record review of the MDS dated [DATE] indicated Resident #1 Resident #1 was understood by others and understood others. The MDS indicated Resident #1 had a BIMS score of 05 and was severely cognitively impaired. Record review of the care plan last revised on 11/20/24 indicated Resident #1 wished to be a full code. During an interview on 1/30/25 at 1:12 p.m. the DON said the facility uses the RAI Manual for care plans. The DON said the facility did not have a care plan policy. During an interview on 1/30/25 at 2:29 p.m. LVN A said the way she would look up a resident's code status was to go into the EMR in the resident's profile and under the resident's picture code status can be seen. LVN A said she did not know if the physician orders or care plan prompted the code status in the EMR. During an interview on 1/30/25 at 2: 39 p.m. MDS Coordinator B said the MDS Coordinators handled the care plans and ensured they were correct. MDS Coordinator B said the MDS Coordinators were Page 1 of 2 675774 675774 01/30/2025 Legend Healthcare and Rehabilitation - Greenville 2300 Jack Finney Blvd Greenville, TX 75402

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsible for ensuring the care plan was correct and was checked 7 days after completing an MDS. MDS Coordinator B said the computer system populated a care plan review. MDS Coordinator B said the MDS, and care plan code status should be the same. MDS Coordinator B said the orders populate the code status on the resident's profile under their picture. MDS Coordinator B said the importance of the orders and care plan code status matching was because the care plan represented the kind of care the facility was giving. During an interview on 1/30/25 at 2:46 p.m. the DON said the MDS Coordinators were responsible for ensuring the care plans were accurate. The DON said she expected the orders and the care plan to match including a resident's code status. The DON said the importance of ensuring the code status on the care plan and orders matched was for accuracy. 675774 Page 2 of 2