Health inspection·January 3, 2024

F 0553 Level of Harm - Potential for minimal harm Residents Affected - Some Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care plans were developed in consultation with the resident and the resident's representative for 8 of 8 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8) reviewed for Comprehensive Care Plan in that: The facility failed to ensure Resident #1, Resident#2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8 or the resident's representative were invited to participate in the residents' care plan meeting. This failure placed residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in the planning of their cares. Findings include: Record review of Resident # 1's face-sheet dated 01/03/2024, revealed an [AGE] year-old female, re-admitted to facility on 06/09/2023. Her diagnosis included: Unspecified Dementia, Severe with Anxiety(patient has excessive restlessness, irritability, muscle tension), Dementia in other Diseases Classified Elsewhere, Moderate, with Other Behavioral Disturbances (verbal, physical aggression, wandering, and hoarding behaviors); Major Depressive Disorder (persistently low or depressed mood, loss of interest in activities), Record review of Resident #1's file revealed no documentation of care plan meetings with resident representative. Record review of Resident #2's face-sheet dated 01/03/2024, revealed a [AGE] year-old female admitted to facility on 08/22/2022. Her diagnosis included Unspecified Dementia, Moderate, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (patient has excessive restlessness, irritability, muscle tension), Essential (Primary) Hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause), Unspecified Asthma, Uncomplicated (Diseases of the Respiratory System). Record review of Resident #2's file revealed no documentation of care plan meetings with resident or resident representation. Page 1 of 3 676139 676139 01/03/2024 Green Oaks Nursing & Rehabilitation 3033 W Green Oaks Blvd Arlington, TX 76016

F 0553 Level of Harm - Potential for minimal harm Residents Affected - Some Record review of Resident #3's face sheet dated 01/03/2024 revealed a [AGE] year-old female re-admitted to facility on 08/18/2023. Her diagnosis included Acute and Chronic Respiratory Failure with Hypoxia (impairment of gas exchange between the lungs and the blood causing hypoxia with or without hypercapnia), Major Depressive Disorder, Recurrent, Unspecified (persistent depressed mood or loss of interest in activities, causing significant impairment in daily life), Essential (Primary) Hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause). Record review of Resident #3's file revealed no documentation of care plan meetings with resident or resident representative. Record review of Resident #4's face sheet dated 01/03/2024 revealed an [AGE] year-old female admitted to facility on 11/22/2022. Her diagnosis included Rheumatoid Arthritis (an autoimmune and inflammatory disease - painful swelling that affects parts of the body), Unspecified, Dementia in Other Diseases Classified Elsewhere, Moderate, with Other Behavioral Disturbance, Adjustment Disorder with Anxiety (verbal, physical aggression, wandering, and hoarding behaviors) Record review of Resident #4's file revealed one care plan meeting held with resident representative on 05/16/2023. No further documentation of care plan meetings offered to resident or resident representative. Record review of Resident #5's face sheet dated 01/03/2024 revealed an [AGE] year-old female re-admitted to facility on 05/16/2023. Her diagnosis included Trigeminal Neuralgia (Chronic pain affecting the trigeminal nerve in the face - nerve carries sensation from the face to the brain), Essential (Primary) Hypertension (high blood pressure that is multi- factorial and doesn't have one distinct cause), Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with Agitation (verbal, physical, aggression, wandering, and hoarding behaviors). Record review of Resident #5's file revealed no documentation of care plan meetings held with resident representative. Record review of Resident #6's face dated 01/03/2023 sheet revealed an [AGE] year-old male re-admitted to facility on 01/25/2019. His diagnosis included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), Unspecified, Chronic Kidney Disease (Longstanding disease of the kidneys leading to renal failure), Unspecified, Essential (Primary) Hypertension (high blood pressure that is multi-- factorial and doesn't have one distinct cause). Record review of Resident #6's file revealed care plan meetings with resident representative on 05/02/2019, 04/23/2020, 07/16/2020, and 01/14/2021. No care plan meetings held after 01/14/2021. Record review of Resident #7's face sheet dated 01/03/2024 revealed an [AGE] year-old female re-admitted to facility on 08/25/2022. Her diagnosis included Alzheimer's Disease with Late Onset (Typically presents with progressive decline in episodic memory, with variable involvement of other cognitive domains), Other Cerebral Infarction Due to Occlusion or Stenosis of Small Artery (mainly caused by pathological changes in cerebral small vessels, which also involve in deep intracerebral hemorrhage). Record review of Resident #7's file revealed no care plan meetings held with resident representative. 676139 Page 2 of 3 676139 01/03/2024 Green Oaks Nursing & Rehabilitation 3033 W Green Oaks Blvd Arlington, TX 76016

F 0553 Level of Harm - Potential for minimal harm Record review of Resident #8's face sheet dated 01/03/2024 revealed an [AGE] year-old female re-admitted to facility on 09/11/2016. Her diagnosis included Alzheimer's Disease, Unspecified (Degenerative disease of the brain), Type 2 Diabetes Mellitus Without Complications (A chronic condition that affects the way the body processes blood sugar - glucose), Essential (Primary) Hypertension (high blood pressure that is multi-- factorial and doesn't have one distinct cause). Residents Affected - Some Record review of Resident #8's file revealed care plan meetings held with resident representative on 07/16/2017, 09/13/2018, 01/31/2019, 05/02/2019, 08/27/2020, and 05/18/2021. Care plan meetings not consistent. Last one held 05/18/2021. On 01/03/2024 at 3:30 PM interviewed DON to request documentation for care plan meetings not uploaded in the sample residents' files. DON could only locate one care plan meeting that was held for Resident #5. DON revealed there were no current care plan meetings of Resident #1, Resident #2, Resident #3, Resident #4, Resident #6, Resident #6, and Resident #7 in sample. ION 01/03/2024, at 4:00 PM, an interview with ADM and DON revealed that the facility had been without a consistent SW on staff. The new SW started on 01/02/2024. Their goals are to ensure that the residents or their representatives are invited to participate in the care plan meeting. E-mailed ADM on 01/05/2024 at 11:45 AM and on 01/08/2024 at 3:18 PM requesting a copy of the facility policy for Care Plans. Did not receive a response from the Administrator. 676139 Page 3 of 3