Health inspection·April 9, 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 1 of 6 residents (Residents #1) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #1's care plan included a diagnosis of Pneumonia. This failure could place residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #1's face sheet dated 03/27/25, reflected an [AGE] year-old female, with an initial admission date of 08/05/22, and a readmission date of 03/12/25. Resident #1 had a diagnosis of Dementia (loss of memory and other thinking abilities) and Secondary Hypertension (high blood pressure). Record review of Resident #1's care plan, dated 03/27/25, did not address her diagnosis of Pneumonia. Record review of the facility's Infection Surveillance Monthly Report, dated 03/27/25, reflected Resident #1 had an infection: Infection onsite date (identification date): 02/24/25 admit date : [DATE] Infection: Pneumonia Status: Open, Confirmed Order: Levaquin Tablet 250 MG (an antibiotic medication) In an interview on 03/27/25 at 3:22 PM, the DON stated she was not sure why Resident #1's care plan did not address pneumonia. She stated Resident #1 started taking the Levaquin on 02/25/25. The DON she would be notified by central intake if a resident went to the hospital and returned with a change or new medication. She stated nurses on the floor or audits that she completed would alert her to changes that occurred in the facility. She stated she would then know the care plan needed to be Page 1 of 4 675806 675806 04/09/2025 The Laurenwood Nursing and Rehabilitation 330 W Camp Wisdom Rd Duncanville, TX 75116

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few updated. The DON stated the risk of pneumonia not addressed on the care plan was missed needs of Resident #1 and potential issues for the resident. In an interview on 03/27/25 at 3:51 PM, the Administrator stated she was not sure why the pneumonia was not listed on Resident #1's Care Plan. She stated she would have to refer to her DON regarding the care plans and the risk of pneumonia not addressed, because that was not her lane. Record review of the facility's policy titled, Care Plans, Comprehensive, dated [DATE], reflected the following: Policy Statement A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. g. incorporate identified problem areas h. incorporate risk factors associated with the identified problems m. Aid in preventing or reducing decline in the resident's functional status and/or element of care 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 675806 Page 2 of 4 675806 04/09/2025 The Laurenwood Nursing and Rehabilitation 330 W Camp Wisdom Rd Duncanville, TX 75116

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #2) reviewed for infection control. Residents Affected - Few The facility failed to add Resident #2 to the infection control log when he was diagnosed with Pneumonia on 03/15/25. This deficient practice could place residents at-risk for infections. Findings included: Record review of Resident #2's face sheet, dated 03/27/25, reflected a [AGE] year-old male, with an initial admission date of 09/04/24, and a re-admission date of 03/21/25. Resident #1 had a diagnosis of Pneumonia (lung infection causing inflammation and fluid buildup), Acute Respiratory Failure (lungs cannot adequately supply oxygen to the blood), Alzheimer's Disease (progressive memory loss and cognitive decline), and Chronic Obstructive Pulmonary Disease (progressive lung disease that makes it hard to breathe). Record review of the progress notes on Resident #2's electronic record dated 03/15/25 reflected Resident #2's doctor ordered the resident to be sent to the hospital after the facility received results of his chest x-ray, which noted the resident had possible pneumonia. The progress notes noted Resident #2 was discharged from the hospital back to the facility on [DATE]. Record review of Resident #2's hospital record dated, 03/15/25, reflected Resident #2 had an encounter diagnosis of Pneumonia and Sepsis (life-threatening medical emergency caused by the body's overwhelming response to infection). The hospital record reflected the encounter diagnosis was, Pneumonia of the right lung due to infectious organism, unspecified part of the lung. Record review of the facility's Infection Surveillance Monthly Report did not reflect that Resident #2 had an infection. Resident #2 was not on the report. In an interview on 03/27/25 at 3:22 PM, the DON stated she was aware Resident #2 went to the hospital and was diagnosed with pneumonia. She stated Resident #2 was treated for pneumonia while at the hospital. The DON stated he returned to the facility around 03/21/25. She stated she was the infection control preventionist, and she was the one responsible for updates on the infection control log. The DON stated any infection that was identified at the facility, would be added to the infection control log. The DON stated she did not add Resident #2 to the infection control log, because he was treated for pneumonia at the hospital. The DON stated she felt there was no risk of Resident #2 not listed on the infection control log, because he was not diagnosed with pneumonia at the facility. The DON stated the facility did not have a policy on infection control logs. In an interview on 03/27/25 at 3:51 PM, the Administrator stated she would have to refer to the DON for information regarding the infection control log. She stated the DON was also the facility's 675806 Page 3 of 4 675806 04/09/2025 The Laurenwood Nursing and Rehabilitation 330 W Camp Wisdom Rd Duncanville, TX 75116

F 0880 Level of Harm - Minimal harm or potential for actual harm infection preventionist. The Administrator stated she was not sure what needed to be on the infection control log. The Administrator stated she would also have to refer to the DON regarding the risk of a resident not listed on the infection control log when the resident was diagnosed upon admission to the hospital. Residents Affected - Few A general infection control policy was requested on 03/27/25 at 3:30 PM but not provided. Record review of the facility's policy titled, Infection Control Guidelines for All Nursing Procedures, dated December 2024, reflected the following: Purpose To provide guidelines for general infection control while caring for residents. 675806 Page 4 of 4