Health inspection·March 21, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure a comprehensive care plan was developed within 7 days after completion of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 4 (Resident #1) residents reviewed for IDT meetings/ care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. Findings included: 1. Record review of Resident #1's face sheet, dated 3/21/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had a diagnoses which included: Enterocolitis Due to Clostridium Difficile, recurrent (A serious inflammation of the colon that can lead to severe symptoms like diarrhea, abdominal pain, and fever), Elevated white blood cell count, other schizoaffective disorders, Unspecified psychosis not due to a substance or known physiological condition, Ataxic gait (an abnormal walking pattern characterized by poor coordination and unsteadiness), Cognitive Communication Deficit, Unspecified Dementia, Unspecified Severity, with Behavioral disturbance. Record review of Resident #1's initial MDS assessment, dated 03/04/2025, reflected a BIMS score of 03, which indicated Resident #1's cognition was severely impaired . Record review of Section GG-Functional Abilities of Resident #1's MDS revealed Resident #1 received Partial/Moderate assistance with Eating, Oral hygiene, Upper body dressing. Attempted record review of Resident #1's electronic health record revealed the care plan was not completed. In an interview with the DON on 03/21/2025 at 2:46pm, she stated she opened the care plans and her and MDS worked together to complete the care plans. She stated she had been on vacation for a week. She stated when she was not at the facility the MDS was responsible. She stated she was not sure why Resident #1's care plan was not completed. She stated that there could have been a miscommunication between her and the MDS worker. She stated the risk of the care plan not being completed was the resident missing care or something happening to the resident. She stated they were behind on their care plans because the staff had quit so they hadn't been able to update all of the care plans yet. Page 1 of 2 675961 675961 03/21/2025 Regency Village 409 W Green Webster, TX 77598

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with MDS on 03/21/2025 at 2:54pm, she stated the care plan was a team effort and IDT completes it together. She stated she was not sure why the care plan wasn't completed. She stated the care plan had to be open by an RN and reported any RN could open the care plan. She stated the risk of the care plan not being completed was the staff may not know what care to provide to the resident. Record review of the Comprehensive Person-Centered Policy, revised December 2016, revealed The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 675961 Page 2 of 2