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 Page 1 of 2 676139 676139 07/30/2024 Green Oaks Nursing & Rehabilitation 3033 W Green Oaks Blvd Arlington, TX 76016

F 0656 Level of Harm - Minimal harm or potential for actual harm hours which the nurses filled out, and she had 21 days to complete the comprehensive care plan. She said Resident #1's care plan was due on 6/26/24 and should have included his diagnoses, medication, fall risk, difficulty walking, cellulitis to lower extremities, cirrhosis to liver, congestive heart failure, chronic obstructive pulmonary disease, and Resident #1's refusal of care. The MDS Coordinator stated the care plan was supposed to be done to see how to care for the resident. Residents Affected - Few In an interview on 07/30/24 at 2:09 pm, the DON stated a comprehensive care plan should have been done for Resident #1. She said the care plan was important because it identified care or if anything needed to be put in place. She said her expectation was for care plans to be done timely. Interview on 07/30/24 at 2:35 pm, the Administrator stated care plans were important to know what care to give the patient. He stated his expectation was for care plans to be done timely. Record review of facility's policy titled, Care Plans - Comprehensive revised December 2009, reflected in part: 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 3. Each resident's comprehensive care plan is designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on the resident's strengths; Reflect the resident's expressed wishes regarding care and treatment goals; Reflect treatment goals, timetables, and objectives in measurable outcomes; Identify the professional services that are responsible for each element of care; Aid in preventing or reducing declines in the resident's functional status and/or functional levels; Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and Reflect currently recognized standards of practice for problem areas and conditions. 4. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). 676139 Page 2 of 2