Health inspection·September 6, 2023

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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights which 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 or 10 residents (Resident #1) reviewed for care plans . The facility failed to ensure that Resident #1's care plan was implemented correctly according to her needs. This failure could place residents at risk for not receiving the necessary care or receiving inappropriate care for their condition and diagnosis. Findings include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included urinary tract infection, bipolar disorder, unspecified psychosis not due to a substance or known, physiological condition, mild protein-calorie malnutrition, mixed hyperlipidemia, history of falling, other dysphagia, oropharyngeal phase other dysphagia, unspecified other difficulty in walking, not elsewhere classified, depression, other dementia in other diseases classified elsewhere, mild, without other behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other lack of coordination, other specified symptoms and signs involving the circulatory and other respiratory systems, cognitive communication deficit, vitamin deficiency, unspecified delusional disorders, other chronic pain, other conductive hearing loss, unspecified muscle weakness (generalized), other unsteadiness on feet, other abnormalities of gait and mobility, other reduced mobility, other need for assistance with personal care and Alzheimer's disease, unspecified Record review of Resident #1's Care Plan, dated 8/21/23, documented the resident was incontinent, was at risk for falls, required 2-person assistance for ADLs . The Care Plan reflected that Resident #1 requires to be in the locked unit. Record review of Resident #1's Quarterly MDS, dated [DATE], documented a BIMS score of 0 out of 15, indicating severe cognitive function. Record review of Resident #1's care plan reflected Resident #1 required the locked dementia unit, dated 11/14/2022. Page 1 of 3 676010 676010 09/06/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's Progress Notes reflected no meetings or progress notes were documented for Resident #1 which stated the resident was being moved from the locked unit. During an interview on 9/6/2023 at 9:08 AM with Charge LVN , Charge LVN stated Resident #1 did not have a room on the locked unit. Residents Affected - Few During an interview on 9/6/2023 at 9:19 AM with Charge LVN, Charge LVN stated the nurses assessed residents every day for changes in condition and if there was a change, they notified the physician as well as the DON so changes could be made to the care plan. Charge LVN stated they were told Resident #1 didn't meet the criteria to be in the locked unit anymore as she didn't wander, have behaviors or any issues . During an interview on 9/6/2023 at 9:46 AM with the Admin , the Admin stated Resident #1 was going to be moved back to the locked unit today since a new room opened up for them. The Admin stated Resident #1 did better in the group setting. During an interview on 9/6/2023 at 9:58AM with the DON, the DON stated staff on the LTC side got Resident #1 up in the morning and gave the resident their medications, then took them to the locked unit where Resident #1 spent the whole day until after dinner. The DON stated after dinner, staff brought Resident #1 back to the LTC side and they went to sleep in their room. The DON stated Resident #1 didn't meet the criteria to be in the locked unit anymore because they were not exit seeking . The DON stated Resident #1 did not try to elope. The DON stated changes like this needed to be evaluated and care planned. During an interview on 9/6/2023 at 1:50 PM with Family #1, Family #1 stated Resident #1 was moved out of the locked unit on 7/17/2023. Family #1 stated they had a meeting with the ADON, and their questions about why Resident #1 was moved were answered. Family #1 stated it wasn't a care plan meeting. During an interview on 9/6/2023 at 2:26 PM with FNP , the FNP stated they talked with the facility, and everyone agreed Resident #1 was a low elopement risk and not exit seeking so they thought they would do ok on the LTC unit. The FNP stated they talked about it, but an order was not written for the change. During an interview on 9/6/2023 at 2:34 PM with the SW , the SW stated Resident #1 was moved out of the locked unit without a meeting with the family. The SW asked if Resident #1 could be moved back to the locked unit as they were not doing as well in the LTC side. The SW stated the team said there were no rooms available for Resident #1 and they didn't meet the criteria to be on the locked unit. During an interview on 9/6/2023 at 2:50 PM with the DON , the DON stated the meeting with the family was not a care plan meeting and the ADON met with the family to answer any questions they had. The DON stated they couldn't tell why the care plan didn't reflect the change as the care plan still stated Resident #1 required a locked unit and that it was a system breakdown. The DON stated the DON and the MDS Coordinator were responsible for completing the care plans. During an interview on 9/6/2023 at 2:59 PM with the Admin, the Admin stated they looked at the care plan for Resident #1 earlier today and Resident #1's care plan shouldn't have said they required the locked facility and that it was a mistake. The Admin stated that the facility fixed the care plan 676010 Page 2 of 3 676010 09/06/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0656 a little bit ago. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy for Comprehensive Person-Centered Care Planning, dated 2022, reflected the IDT shall develop a comprehensive person-center care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in a comprehensive assessment, and that the baseline care plan includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. Residents Affected - Few 676010 Page 3 of 3