Health inspection·September 28, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of the resident's admission for one of eight residents (Residents #177) reviewed for baseline care plans. The facility failed to complete a baseline care plan for Residents #177 within 48 hours of admission which included the minimum required healthcare information which included physician orders, dietary orders, therapy services and social services. This failure could place residents at risk of not receiving effective and person-centered care. Findings include: Record review of Resident#177's faced sheet, dated 09/27/2023, reflected a 95 -years-old-male who was admitted to the facility on [DATE]. His diagnoses included: hemiplegia (paralysis of one side of the body) affecting left non-dominant side, hypertension, dysphagia (difficulty or discomfort in swallowing, as a symptom of disease) following cerebral infarction (type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain), muscle weakness, lack of coordination, and repeated fall. Record review of Resident #177's electronic clinical record, on 09/26/23, revealed no Baseline Care Plan. An incomplete baseline care plan was done on 09/27/2023. Interview on 09/27/23 at 02:06 PM with the DON revealed Resident #177's base line care plan was not done after 48 hours of admission and stated the care plan was posted today, 09/27/2023. The DON stated Resident # 177's admission paper was not reviewed, and she was not aware of the missing base line care plan. The DON stated baseline care plans should be completed by the nurses completing the residents' admission. She stated the baseline care plans were important because they captured the immediate care needs of residents coming into the facility. She stated they should be completed within 24 - 48 hours. she stated the facility's expectation was they be completed with 24 hours. She stated not having a baseline care plan could limit the facility's ability to meet the resident's care needs. She said would typically complete admission reviews to ensure all care plans were completed. Interview on 09/28/23 at 10:00 AM with MDS coordinator nurse D revealed she worked as the MDS coordinator nurse at a corporate level and was no longer assigned to the facility starting last Thursday 09/21/2023. She stated baseline care plans should be completed by the nurses completing the Page 1 of 3 675822 675822 09/28/2023 Beltline Healthcare Center 106 N Beltline Rd Garland, TX 75040

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents' admission and the MDS Nurse Coordinator revised it when developing the MDS and the comprehensive care plan after 14 days of residents' admissions. Interview on 09/28/23 at 10:19 AM with RN P revealed she had been with the facility for two weeks and was not able to do an admission yet. RN P stated the RNs were responsible for initiating a base line care plan in the first 48 hours of residents' admission. RN P stated the care plan outlined the care residents needed. RN P stated without a base line care plan the residents' care would not be accurately provided. RN P stated the DON was responsible for completing admission reviews to ensure all admission documentation was completed, which included baseline care plan. Interview on 09/28/23 at 10:27 AM, MDS Coordinator Nurse S revealed she started with the facility yesterday, 09/27/2023, as travel nurse MDS coordinator. She stated the purpose of care plans were to basically monitor the residents, and their needs. She stated the baseline care plan was a tool used for the residents in the planning of their care and their needs. She stated the MDS coordinator nurses had 14 days to revise, and develop the residents' comprehensive care plan, and MDS after admission. She stated the nurses in the ward, and the DON were responsible for developing the baseline care plan for the resident after 48 hours of admission. Record review of the facility policy, Base Line Care Plan, dated 03-2019, reflected, Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission. 675822 Page 2 of 3 675822 09/28/2023 Beltline Healthcare Center 106 N Beltline Rd Garland, TX 75040

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm Resident #177 Residents Affected - Few Care Planning See Surveyor Khadija Jaddour's notes; citation for Baseline Care Planning. 675822 Page 3 of 3