Health inspection·July 31, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 conduct initially and periodically 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 condition for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans, in that: The facility failed to ensure a comprehensive care plan for Resident #1 was completed since the resident's admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings were: Record review of Resident #1's face sheet, dated 07/12/2023, revealed she had an admission date of 03/29/2023 and diagnoses that included: Nontraumatic Intracerebral Hemorrhage (bleeding inside the skull), Muscle wasting and Atrophy (decrease in a body part), and Hemiplegia (one-side muscle paralysis or weakness). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 03, which indicated severe cognitive deficit. Record review of Resident #1's medical record revealed there was no comprehensive care plan for the resident. In an interview with ADON A and the Regional Nurse, dated 07/12/2023 at 11:44 AM, they both verified that no care plan was on file or had been completed since residents' admission. In an interview with the Regional Nurse, dated 07/14/2023 at 10:57 AM, the Regional Nurse stated the person who was responsible for writing the care plans at the time was no longer employed at the facility. The Regional Nurse stated the facility had a new MDS nurse they had recently assigned and the care plans were checked every morning and the Social Worker sent out care plan letters and the care plans were reviewed by the Interdisciplinary Team. Record review of the facility's policy titled, Comprehensive Care Plans, dated 02/10/2021, revealed, The comprehensive care plan will be developed within 7 days after the completion of the Page 1 of 2 675883 675883 07/31/2023 Southeast Nursing & Rehabilitation Center 4302 E Southcross Blvd San Antonio, TX 78222

F 0656 comprehensive MDS assessment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675883 Page 2 of 2