Health inspection·May 1, 2024

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 interviews 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 meet professional standards of quality care within 48 hours of the resident's admission for 1 of 5 residents (Resident #19) whose records were reviewed for baseline care plans. The facility failed to ensure Resident #1 had a baseline care plan developed and implemented within 48 hours upon admission on [DATE]. The facility failed to ensure Resident #1's baseline care plan addressed the resident as being a high fall risk. This failure could place the residents at risk for not receiving care and services required to meet their individual needs from the date and time they were admitted to the facility. Findings included: Record review of Resident #1's Face Sheet, dated 4/30/2024, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, heart failure, chronic obstructive pulmonary disease (a disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), anxiety disorder (a group of mental illnesses that cause constant fear and worry), and age-related physical debility (losing mobility and strength). Record review of Resident #1's clinical record revealed a baseline care plan had not been completed until 04/30/2024 (5 days after admission). Record review of Resident #1's baseline care plan revealed it failed to address the resident being a high fall risk. The baseline care plan was negative for history of falls within the last year. Record review of Resident #1's Morse Fall Risk Assessment, completed 04/25/2024 revealed the resident scored a 60 which indicated a high fall risk. Record review of Resident #1's admission Data Collection Tool, dated 4/26/24, revealed the resident had a fall last month and the resident had a fall in the last 2-6 months. In an interview on 05/01/2024 at 10:40 am, the DON stated the baseline care plan should have been completed within 48 hours but was not due to the resident arriving Friday evening and the MDS Page 1 of 2 675831 675831 05/01/2024 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinator was off during the weekend. The resident had a history of falls at home, and it should have been noted on the baseline care plan. The DON said the failure had potential for residents at risk of not getting needed care that would have been identified. She said she is working on a plan to make sure care plans are completed within 48 hours if they come in during the weekend. In an interview on 05/01/2024 at 11:09 am, the MDS Coordinator said she was responsible for ensuring the baseline care plans were completed within 48 hours. She said the baseline care plan was not completed within 48 hours due to the resident being admitted Friday evening and she was already off for the day when the resident arrived at the facility. She did not return to work until the following Monday morning and that it was completed at that time. The MDS Coordinator said she did not remember seeing any documentation indicating the resident was a high fall risk, but it should have been addressed in the baseline care plan. She said there is currently no one to ensure a care plan is completed within 48-hours on the weekend. Record review of the facility policy Care Plans - Baseline, dated as revised December 2016, revealed the following [in part]: Policy Statement: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation: 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed with forty-eight (48) hours of the resident's admission. 2. the Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders. 675831 Page 2 of 2