Health inspection·April 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 observation, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans. Resident #1's comprehensive care plan did not reflect Resident #1's mechanical soft texture diet. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings include: A record review of Resident #1's face sheet dated 04/30/2025, reflected a [AGE] year-old male who was re-admitted to the facility on [DATE]. Resident #1's diagnoses included: unspecified dementia (a condition that causes a decline in thinking, memory, and reasoning abilities), seizures (sudden, temporary disruption of the brain's normal electrical activity, resulting in changes in behavior, movement, feelings, or consciousness.), muscle wasting and atrophy (the muscles are shrinking and losing strength), lack of coordination (having difficulty controlling your movements and making them work together smoothly) and muscle weakness (reduced ability of the body to contract muscle properly, resulting in a lower strength in one or more muscle). A record review of Resident #1's Quarterly MDS assessment, dated 04/10/2025, reflected the resident had a BIMS score of 99, which indicated the BIMS interview was not completed. Resident #1's Quarterly MDS reflected Resident #1 was dependent in the following areas: toileting hygiene, shower/bathe self, and personal hygiene. Resident #1 required substantial/maximal assistance with eating, oral hygiene, and putting on/taking off footwear. Resident #1's Quarterly MDS also reflected he received a mechanically altered diet. A record review of Resident #1's care plan, dated 04/30/2025, reflected Resident #1's care plan did not reflect Resident #1's mechanical soft diet. A record review of Resident #1's physician orders dated 04/30/2025, reflected Resident #1 had a physician order dated 12/08/2023 for regular diet, mechanical soft texture, regular consistency. During an observation on 04/30/2025 at 12:10 pm., Resident #1 was observed eating a mechanical soft Page 1 of 2 675867 675867 04/30/2025 Kerens Care Center 809 NE 4th St Kerens, TX 75144

F 0656 diet during lunch in the dining area with the assistance of LVN A. Level of Harm - Minimal harm or potential for actual harm Attempted to interview Resident #1 on 04/30/2025 at 12:10 pm., Resident #1 could not be interviewed due to his severe cognitive impairment. Residents Affected - Few During an interview with LVN A on 04/30/2025 at 12:50pm, LVN A stated that Resident #1 received a mechanical soft diet. LVN A stated Resident #1 has a physician order for his mechanical soft diet. LVN A stated during the dining times she reviews the meal tickets to ensure residents are receiving the correct texture diet. LVN A was not aware that Resident #1's care plan did not reflect his mechanical soft diet. During an interview with the MDS Coordinator on 04/30/2025 at 3:00pm, the MDS Coordinator stated that Resident #1's mechanical soft diet should have been reflected on his care plan. The MDS Coordinator stated she and other department heads were responsible for ensuring that care plans were up to date and accurate. The MDS Coordinator stated if a resident's care plan was not accurate then the resident would not receive the appropriate care needed. During an interview with the ADM on 04/30/2025 at 3:50pm, the ADM stated Resident #1's mechanical soft diet should have been reflected on his care plan. ADM stated it was the MDS Coordinator's responsibility for ensuring care plans have the most accurate information for the resident's care. ADM stated that Resident #1 could have received the wrong texture diet because of his care plan not reflecting his mechanical soft diet. A record review of the facility's Comprehensive Care Planning policy, not dated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the followingThe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs . 675867 Page 2 of 2