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. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675961 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Village 409 W Green Webster, TX 77598 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)