Health inspection·May 24, 2023

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. 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 assess each resident quarterly (every 3 months) using the MDS (minimum data set) form specified by the state and approved by CMS for one (Resident #33) of five residents reviewed for quarterly assessments. Residents Affected - Few The facility failed to ensure Resident #33 had a quarterly MDS assessment . This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions. Findings: Record review of Resident #33's face sheet, dated 05/24/23, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease , failure to thrive, and dementia. Record review of Resident #33's electronic health chart revealed the last MDS Assessment was completed on 01/26/23 . There was no record of a more recent one completed. In an observation and attempted interview on 05/22/23 at 10:00 AM with Resident #33 revealed she was lying in bed in her room and was not responding to questions. In an interview on 05/23/23 at 2:15 PM with the MDS Coordinator revealed she was the one responsible for ensuring MDS Assessments were completed for each resident at least quarterly or every 92 days. The MDS Coordinator said the electronic health record system automatically created a schedule that tells the staff when a resident's MDS Assessment was due for the next quarter. The MDS Coordinator said she looked at the schedule and saw that Resident #33's was not due until June 2023 and had skipped her quarterly March 2023 MDS Assessment due to a glitch. The MDS Coordinator said that the last MDS assessment completed for Resident #33 was finalized in January 2022, so she was due for one in March 2023 for her next quarterly MDS Assessment. The MDS Coordinator said the purpose of the quarterly MDS Assessment was to catch up on any changes and because it was required by CMS. In an interview on 05/23/23 at 2:40 PM with the DON revealed the MDS Coordinator was responsible for ensuring MDS Assessments were completed quarterly. The DON said the purpose of the quarterly MDS Assessment was to capture information on the resident and that time and update the assessment when changes occurred based on the resident's abilities at that time. The DON said the electronic health record system created an automatic schedule and skipped Resident #33's March 2023 quarterly MDS Assessment after her last one was finalized in January 2023. Page 1 of 4 676329 676329 05/24/2023 Continuing Care at Highland Springs 7910 Frankford Road Dallas, TX 75252

F 0638 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy, revised 06/21, and titled MDS Completion and Management reflected: MDS Tracking .3. A Quarterly MDS is to be completed, per the MDS 3.0 RAI Manual, by the team on each resident who remains in skilled nursing. 4. The MDS Coordinator or designee maintains the electronic schedule for MDS completion with the EMR application. 5. The MDS Coordinator or designee schedules subsequent assessments. Residents Affected - Few 676329 Page 2 of 4 676329 05/24/2023 Continuing Care at Highland Springs 7910 Frankford Road Dallas, TX 75252

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 6 residents (Residents #25) for care plan revisions, in that: The facility failed to ensure Resident #25's care plan was revised to include not using the gait belt during transfers These failures could place residents at risk of receiving inappropriate care. The findings include: Record review of Resident #25's face sheet dated 05/23/23 revealed an initial admission date of 03/01/23. Admitting diagnoses included displaced fracture of base of neck of left femur, periprosthetic (broken) fracture around internal prosthetic left hip joint, adult failure to thrive, bipolar disorder, dyskinesia (uncontrolled involuntary movement), dementia and osteoporosis MDS assessment review for significant change (acute hospital) dated 04/06/23 reflected the Resident #25 had a BIMS score of 01 (indicating severe cognitive impairment). She needed extensive to total assistance with ADLs. Record review of Resident #25's care plan, last revised 05/19/23 reflected Resident #25 needed a gait belt Observation on 05/23/23 at 12:04 pm revealed RN A assisting Resident #25 from the floor to the wheelchair by lifting Resident #25 under the arms. In an interview on 05/23/23 at 02:38 PM with RN A, she stated the Resident #25 had behaviors. Nurse stated if staff used the gait belt on Resident #25, Resident #25 would think that they were restraining her down, and the resident would start fighting and she could harm herself. Asked why the care plan indicated to use the gait belt, nurse stated then the care plan needed to be updated to indicate the resident did not use the gait belt. Nurse stated Resident #25 was able to assist during transfers, so the staff only did support the resident, so she did not lose balance. RN A stated the care plan needed to be revised and updated so that the resident's care was provided without any adverse effects. In an interview on 05/23/23 at 02:42 PM with the DON, she stated the Resident #25 had behaviors for a few months and she will not allow the staff to apply the gait belt because she felt like she was being restrained. Asked why the care plan indicated to use the gait belt, she stated the care plan needed to be updated to indicate the resident could not use the gait belt or the Hoyer lift because she was not able to. DON stated the Clinical Manager was responsible for revising and updating the care plan. She further stated the technique the staff used could have been the best way to transfer Resident #25 because the resident was able to bear much weight. DON stated the care plan needed to be revised and updated so that the staff were able to provide appropriate care to the resident. In an interview on 05/23/23 at 03:16 PM with the Clinical Manager, he stated he completed and revised the care plan. He further stated the care plan needed to reflect the resident's needed care. 676329 Page 3 of 4 676329 05/24/2023 Continuing Care at Highland Springs 7910 Frankford Road Dallas, TX 75252

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regarding Resident #25's care plan, he stated her care plan had been revised on 05/19/23. He further stated Resident #25 was not supposed to use the gait belt during transfers because the resident felt like she was restrained. The Clinical Manager stated he was supposed to update the resident's care plan to reflect the that she did not need the gait belt, but he didn't. He stated he will update the care plan. Clinical manager stated the care plan needed to be revised to indicate the resident's care needs and the staff to be aware on how to provide care to the resident. Review of the facility policy dated 05/23/23 and titled Care/Service Plans reflected, .Each guest/resident individualized care/service plan will be revised to reflect any changes in condition and will be reviewed at designated internals at a minimum based on service line (Skilled Nursing/Long Term Care/Assisted Living/Memory Care). 8. Care Plans will be reviewed, revised if applicable, on an ongoing basis by the interdisciplinary team with any change in condition and after each assessment, including both comprehensive and quarterly review assessments. 676329 Page 4 of 4