Health inspection·December 28, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to conduct a comprehensive assessment within 14 calendar days after admission as required for 1 of 5 resident records reviewed (Resident #2) in that: Resident #2 did not have an initial comprehensive assessment completed. This failure could place newly admitted residents at risk for not having needs met and could decrease the resident's ability to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings include: Record review of Resident #2's face sheet, dated 12/28/2023, revealed the resident was an [AGE] year-old female that was admitted to the facility on [DATE], with diagnoses of dementia with behavioral disturbances (memory loss that creates aggression, agitation, and anxiety). hypotension (low blood pressure), mood disorder (general state or mood that is distorted or inconsistent with the resident's circumstances and interferes with their ability to function), dementia with behavioral disturbances ( memory loss that creates aggression, agitation and anxiety) chronic kidney disease, stage 3 (kidney has mild to moderate damage and are less likely to be able to filter out waste and fluid from your blood) epilepsy (disorder in which nerve cell activity in the brain is disturbed causing seizures), and seizures (sudden uncontrolled burst of electrical activity in the brain). Record review of Resident #2's electronic admission MDS Assessment, dated 12/19/2023, revealed a Interview on 12/28/2023 at 2:00 PM., with the MDS Coordinator confirmed that Resident #2's admission comprehensive assessment dated [DATE] was in progress, had not been completed as of 12/28/2023 and was not completed within the required time-period. She reported that she was behind in her assessments and that she was trying to catch up after being new in the position. She revealed that this failure could place the residents at risk for not receiving having their care areas identified. She reported that the DON is responsible for overseeing that the MDS was completed timely. Review of a copy of the facilities policy and procedures titled Resident Assessment, dated 2003 revealed the following: 1) Page 1 of 5 676148 676148 12/28/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0636 A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument. Level of Harm - Minimal harm or potential for actual harm 2) Residents Affected - Few The assessment will include at least the following: A) Medically defined conditions and prior medical history B) Medical status measurement C) Physical and mental functional status D) Sensory and physical impairments E) Nutritional status and requirements F) Special treatments and procedures G) Mental and psychosocial status H) Discharge potential I) Dental conditions J) Activities potential K) 676148 Page 2 of 5 676148 12/28/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0636 Rehabilitation potential Level of Harm - Minimal harm or potential for actual harm L) Cognitive status Residents Affected - Few M) Drug therapy 3) RAI assessments must be conducted within 14 days after the date of admission: promptly after a significant change in the residence physical or mental condition (as soon as the resident stabilizes at a new functional or cognitive level, or within two weeks, whichever is earlier). 4) The results of the assessment are used to develop, review, and revise the resident's comprehensive plan of care. 5) Each assessment must be conducted or coordinated by registered nurse who signs, certifies the completion of the assessment. 676148 Page 3 of 5 676148 12/28/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

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 a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's medical, nursing, and mental and psychosocial needs for 1 (Resident #1) of 5 residents reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered for Resident #1 with collaboration of the IDT. This failure could affect all newly admitted residents by placing them at risk for not having their individual needs met. Findings included: Record review of Resident #1's face sheet, dated 12/28/2023, revealed the resident was admitted to the facility on [DATE], with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental function), hypertension (high blood pressure), adult failure to thrive (decline in older adults that manifest as a downward spiral of health and abilities), mood disorder (general state or mood that is distorted or inconsistent with the resident's circumstances and interferes with their ability to function), dementia with behavioral disturbances ( memory loss that creates aggression, agitation and anxiety). No documentation of a comprehensive care plan was found in the records. Review of Resident #1's comprehensive admission MDS assessment dated [DATE], revealed the following areas were identified in Section V (Care Area Assessment Summary) to be care planned, with the RN completion signature date of 12/07/2023. 1) Cognitive loss/dementia 2) Urinary Incontinence 3) Behavioral Symptoms 4) Falls 5) 676148 Page 4 of 5 676148 12/28/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0656 Nutritional Status Level of Harm - Minimal harm or potential for actual harm 6) Pressure Ulcers Residents Affected - Few 7) Psychotropic Drug Use Record review of Resident #1's electronic medical record dated 12/06/2023, revealed that no documentation of a comprehensive care plan or an IDT meeting was found in the records. An interview with the MDS Coordinator on 12/28/2023 at 2:00 PM, she confirmed there was no comprehensive person-centered care plan, or an IDT meeting for Resident #1. She stated the facility was behind on comprehensive care plans and that she was newer in the MDS position. She stated that this failure could place residents at risk for not having their care areas identified and addressed. During an interview on 12/28/2023 at 3:30 PM, the DON stated that it was the responsibility of the MDS Coordinator to make sure the care plans were created timely. She reported that she was the one that would view and oversee completion of the Comprehensive Care plan being completed. Record review of a copy of the facilities policy and procedures titled, Comprehensive Care Planning, not dated, revealed the following: Comprehensive Care PlanningThe facility will develop and implement A comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives in time frames to meet a residence medical, nursing, and mental in psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the followingthe services that are to be furnished to attain or maintain the residence highest practicable physical, mental, and psychosocial well-being, and the right to refuse treatment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the residents medical, physical, mental, and psychosocial needs. 676148 Page 5 of 5