Health inspection·January 2, 2025

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected her actual fall on 11/26/2024 and included a care plan regarding how to prevent further falls. These deficient practices could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: Record review of Resident #1's face sheet, dated 01/02/2025, revealed Resident #1 was [AGE] years old, female, and admitted to the facility on [DATE] with diagnoses which included: aftercare following joint replacement surgery (procedure in which a surgeon removed a damaged joint and replaces it with a new and artificial part), osteoarthritis (degenerative joint disease), insomnia (difficulty of sleeping), muscle weakness, difficulty in walking, and obstructive and reflux uropathy (urine cannot drain through the urinary tract). Record review of Resident #1's admission MDS assessment, dated 11/29/2024, revealed Resident #1's BIMS score was 3 for severe cognitive impairment, she was dependent (Helper does all of the effort) for chair-to-bed transfer, and required substantial/maximal assistance (Helper does more than half the effort) to toilet transfer. Record review of Resident #1's incident report, dated 11/26/2024, revealed Resident #1 tried to walk without assist, losing balance, and had a fall landing on her right side on the hallway. Record review of Resident #1's communication note, dated 11/27/2024, revealed the facility had a meeting with the resident's family and discussed one to one care, but the facility could not provide one to one care, so the family would hire 24-hour care giver for the resident, and the facility increased monitoring the resident. Page 1 of 2 676228 676228 01/02/2025 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's comprehensive care plan, dated 11/22/2024, revealed The resident is a high risk for falls related to confusion, deconditioning, and unaware of safety needs - for intervention, anticipate and meet the resident's need, be sure the resident's call light is within reach, follow facility fall protocol, and keep the bed in the lowest position. Further record review of the resident's comprehensive care plan revealed there was no updated care plan after the fall occurred on 11/26/2024 regarding 24-hour one to one care by family members and increased monitoring by the facility staff. Interview on 01/02/2025 at 12:16 p.m. with the DON acknowledged Resident #1 fell on [DATE], and the family provided 24-hour one to one care to the resident, and the facility increased monitoring the resident to almost every one hour after the fall was occurred on 11/26/2024. However, the DON did not develop and update the care plan after the fall of 11/26/2024. It was the DON's responsibility to develop and update the care plan after reviewing each actual fall. Further interview with the DON stated she did not know what reason she did not develop and update the care plan after the fall. DON said she might forget developing and updating the care plan, and not developing and updating the care plan might cause lack of care to the resident. Record review of the facility policy, titled Care Planning - Interdisciplinary team, revised on 04/2009, revealed . 2. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team Meeting. 676228 Page 2 of 2