Health inspection·July 8, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care that was developed within 48 hours of a resident's admission for one ( Resident #2) of three residents reviewed for baseline care plans. The facility failed to ensure Resident #2's baseline care plan was specific to the Resident #2 and contained specific instructions needed to provide effective care. This failure placed newly admitted residents at risk of not being informed of their initial goals and services, not receiving continuity of care and communication among nursing home staff, decreased resident safety and safeguard against adverse events that are most likely to occur right after admission. Findings included: Review of Resident #2's undated electronic admission Record revealed the resident was a [AGE] year-old female admitted to the facility 07/03/224 with diagnoses to include but not limited to dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hyperlipidemia (an elevated level of lipids) Review of the baseline care plan dated 07/04/2024 revealed the template for the base line care plan was printed. However, it did not contain any details specific to Resident #2's needs. An interview on 07/08/2024 at 4:50 PM with the Assistant Director of Nursing revealed he completed the template for the baseline care plan. However the MDS coordinator was responsible for completing the full comprehensive assessment which would then update the care plan. He stated he did not feel there was a risk due to staff having orders that were available to staff. Interview on 07/08/2024 at 5:06 PM with the Director of Nursing revealed the care plan was going to be updated that day following the care plan conference. However the resident's family decided to discharge the resident following the care plan meeting. The Director of Nursing stated she did not feel there was a risk to the resident due to staff having access to admission orders in point of care (a system for documenting care) Interview on 07/08/2024 at 5:30PM with the Administrator revealed the baseline care plan template was meant to guide staff on completing the care plan. However, it should still be specific to the (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 4 Event ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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)