Health inspection·April 21, 2025

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 observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objective and time frames to meet a resident's medical, nursing, mental and psychosocial needs for 1 (Resident #23) of 6 residents reviewed for care plans. The facility failed to ensure that Resident #23's care plan included information regarding his tube feedings that were ordered on 4/17/2025. The failure could place residents at risk of not receiving appropriate care and interventions to meet their needs. Findings included: Record review of Resident #23's face sheet dated 4/19/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Personal history of Traumatic Brain Injury and Gastrostomy Status (a tube inserted into the stomach that nutrition and medications can be administered). Record review of Resident #23's quarterly MDS dated [DATE] revealed a BIMS score of 3 that suggested severe cognitive impairment. Record review of physician's order for Resident #23 dated 4/17/25 at 8:20 p.m. revealed Isosource (tube feeding) 1.5 Cal 0.07 gram-1.5 kcal/mL liquid for tube feed, 50 ml/hour Enteral Tube (a feeding tube that allows liquid food to enter the stomach or intestine through a tube) with start of 4/17/2025 at 8 p.m. Record review of Resident #23's April MAR revealed Isosource (tube feeding) 1.5 Cal 0.07 gram-1.5 kcal/mL was administered on 4/18/25. Record review of Resident #23's Nursing Clinical Notes by LVN B dated 4/17/25 at 11:04 p.m. revealed tube feeding was started at 8:30 p.m. Record review of Resident #23's Care Plan Report dated 4/19/25 revealed no information regarding tube feedings. Record review of Resident #23's Care Plan Report dated 4/21/25 revealed Resident #23 was at risk Page 1 of 2 676207 676207 04/21/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0656 Level of Harm - Minimal harm or potential for actual harm for impaired nutritional status and complications due to enteral feeding with Isosource 1.5 with created date of 4/21/25 at 8:41 a.m. for the impaired nutritional status section. Observation on 4/19/25 at 10:05 a.m. revealed that resident had tube feeding infusing via a pump through his g-tube (a tube inserted into the stomach that nutrition and medications can be administered). Residents Affected - Few During interview on 4/21/25 at 8:57 a.m., the DON said the MDS nurse was responsible for adding long term items like dietary needs to the care plan and the ADON can add short term items like falls to the care plan. The DON said the ADON was on vacation at the day of the interview. During interview on 4/21/25 at 9:52 a.m., the Patient Care Coordinator said he put problems that were generated from the MDS on the resident's care plans. The Patient Care Coordinator said that if it was a new order or problem, then the nurse, unit manager or DON puts the instructions on the care plan as they work interdisciplinary. Surveyor attempted to call ADON on 4/21/25 at 10:36 a.m. but did not answer and surveyor was unable to leave a voicemail. During interview on 4/21/25 at 11:33 a.m., the DON said the care plan reflects the plan of care for the resident so if the care plan is not updated timely then the staff would not know how to take care of the resident. The DON said that a resident's labs or electrolytes could be off and weight loss would be the main concern if a resident does not receive their tube feeding. The DON confirmed that she found documentation regarding Resident #23's tube feeding being administered starting 4/17/25. Record Review for facility's policy titled Care Plans, Comprehensive Person-Centered with revised date March 2022 revealed Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 676207 Page 2 of 2