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 Page 1 of 4 676248 676248 07/08/2024 Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident. The Administrator stated the there was no risk to residents due to the information already being in point of care Review of the facility Social services polices and procedures policy dated 10/01/2020 revealed Social Services Staff will participate in the development of a baseline and or comprehensive care plan for each patient/resident according to the following time frames and facility procedures: Baseline Care Plan Developed and initiated within 48-hours of admission The person-centered care plan is interdisciplinary and created to guide facility staff in providing the treatment, care and services necessary for the patient/resident to obtain and maintain the highest physical, mental, and psychosocial well-being possible. The plan is also used to promote patient/resident and family involvement in planning care. 676248 Page 2 of 4 676248 07/08/2024 Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice one (Resident #1) of three residents reviewed for quality of care. Residents Affected - Few The facility failed to complete a weekly skin assessment for Resident#1 This failure could place the resident at risk for diminished quality of care. Findings included: Resident #1's electronic face sheet printed 07/08/2024 reflected a [AGE] year-old female who admitted to the facility initially on 02/12/2024 and re admitted on [DATE] with diagnosis that included but not limited to heart failure(a condition that develops when your heart doesn't pump enough blood for your body's needs), and dementia(impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Resident #1's MDS assessment dated [DATE] revealed a quarterly BIMS score of 11 which indicated the resident was moderately cognitively impaired. Review of Resident #1's care plan dated 05/08/2024 revealed Resident #1 was at risk for pressure ulcers due to poor bed mobility with goals for skin to remain intact. Resident #1's care plan included interventions to included keeping skin dry and clean and reporting any signs of skin breakdown. Review Resident #1's weekly skin assessment dated [DATE] revealed skin was warm, dry ,normal color with no skin alterations. There was not skin assessment after 06/25/2024. Interview on 07/08/2024 at 1:00PM with Resident #1 revealed she was in pain on her lower back and felt she had some type of skin issue on her lower back and tailbone area. Resident #1 stated staff had not assessed her skin however they were aware that she was having issues Interview on 07/08/2024 at 3:38PM with RN A stated she was responsible for weekly skin assessments for Resident #1. RN A stated she completed the skin assess on 07/03/2024. However, she forgot to document the assessment. RN A stated all residents received weekly skin assessments. RN A stated Resident #1 did not have any issues with her skin. Interview on 07/08/2024 at 5:06 PM with the Director of Nursing revealed all residents were to have weekly skin assessments by nursing staff regardless of whether skin issues had been reported. The Director of Nursing stated residents were also assessed daily by CNAs for staff for skin issues as well. The Director of Nursing stated the risk of not completing the weekly skin assessments would be that skin issues would be overlooked and not treated. Interview on 07/08/2024 at 5:30PM with the Administrator revealed the nurses were responsible for completing skin assessments weekly on all residents. He stated aides were also doing skin assessments daily while providing care to residents. The Administrator stated the risk of the nurse not completing the weekly skin assessment would be that a skin issued could be missed and proper treatment would not be provided. 676248 Page 3 of 4 676248 07/08/2024 Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy Wound Care policies and procedures reference dated 2017 revealed Weekly skin checks should be performed and documented by licensed staff on all patients/residents paying attention to: The surfaces of the skin that come in contact with the bed and chair. Bony prominences (heels, tailbone, shoulder blades, elbows, back of the head etc.).The surfaces of the skin that come in contact with each other and any orthotic device, medical device, tube, brace, or positioning device. 676248 Page 4 of 4