Health inspection·July 30, 2024

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 observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 1 of 5 residents (Resident #1) reviewed for Care Plans. The facility failed to complete a comprehensive care plan for Resident #1. This failure could place residents at risk of not receiving necessary care and services. Findings included: Review of Resident #1's admission Record, dated 07/30/24, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure with hypercapnia, chronic viral Hepatitis C, morbid obesity, depression, obstructive sleep apnea, chronic obstructive pulmonary disease, other cirrhosis of liver, cellulitis of right and lower limb, and patient's other noncompliance with medication regimen for other reason. Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 14, indicating intact cognition. The MDS further reflected Resident #1 was dependent on staff for toileting and showering, required partial/moderate assistance of staff for personal hygiene, and supervision for eating. The MDS revealed Resident #1 was frequently incontinent of bladder and bowel, had an external catheter and was at risk of developing pressure ulcers/injuries. The MDS reflected Resident #1 was taking an anticoagulant and diuretic and was on oxygen therapy. Review of Resident #1's care plan, dated 06/07/24, revealed [Resident Name] has little or no activity involvement r/t Resident wishes not to participate. The care plan did not reflect any other care areas. Observation and interview on 07/30/24 at 11:13 am revealed Resident #1 lying in bed and had O2 on. Resident declined to answer questions. In an interview on 07/30/24 at 1:44 pm, the MDS Coordinator stated she had worked there for 6 months. She stated she was responsible to complete the comprehensive care plan, and she said she had gotten behind and was trying to get caught up. She said there was another MDS Coordinator that would be starting in Mid-August. She said the baseline care plan was supposed to be done in the first 24 (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: 676139 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 676139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Oaks Nursing & Rehabilitation 3033 W Green Oaks Blvd Arlington, TX 76016 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)