Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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, interviews, and record reviews the facility failed to implement a comprehensive
person-centered care plan for eight (8) of eight (8) residents (Residents #1 through Resident #8) reviewed
for care plans.
The facility failed to ensure Resident #1 through Resident #8's care plans were updated and revised to
reflect a recent COVID infection.
This failure placed residents at risk of not having their individualized needs met in a timely manner and
communicated to providers and could result in injury and a decline in physical well-being.
Findings included:
Record Review of the facility Root Cause Analysis of a self-reported incident revealed the SNF had a
COVID outbreak that started on11/14/2023. Further review indicated a total of eight residents (Resident #1
through #8) tested positive between 11/14/2023 and 11/24/2023.
Review of Resident #1's face sheet dated 12/21/2023 reflected a [AGE] year-old male admitted to the
facility on [DATE] with diagnosis that included: close fracture of the right femur (broken hip), Osteoarthritis,
Type 2 Diabetes (blood sugar regulation disorder), heart disease and updated diagnosis on 11/14/2023 of
COVID-19.
Review of Resident #1's care plan with a closed date of 11/21/2023, reflected no problem/focus related to a
diagnosis of a Covid infection as well as no goals or interventions for care for the Covid infection.
Review of Resident #2's face sheet dated 12/21/2023 reflected a [AGE] year-old female admitted to the
facility on [DATE] with diagnoses that included: Alzheimer's, muscle weakness, cognitive communication
deficit, Hypertension (high blood pressure) and an updated diagnosis on 11/16/2023 of COVID-19.
Review of Resident #2's care plan dated last completed 11/21/2023, reflected no problem/focus related to a
diagnosis of a Covid infection as well as no goals or interventions for care.
Review of Resident #3's face sheet dated 12/21/2023 reflected a [AGE] year-old female admitted to the
facility on [DATE] with diagnoses that included: Fracture of left humerus (broken left upper arm), Hemiplegia
(partial paralysis), Hyperlipidemia (high cholesterol), Hypertension (high blood pressure and cognitive
communication deficit. There was no entry on the face sheet to include an updated
(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 3
Event ID:
676364
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
676364
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/21/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Morada Temple
4312 S 31st St
Temple, TX 76502
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)
F 0656
diagnosis for COVID-19.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident #3's care plan with a closed date of 12/6/2023 reflected no problem/focus related to a
diagnosis of a Covid infection as well as no goals or interventions for care.
Residents Affected - Some
Review of Resident #4's face sheet dated 12/21/2023 reflected a [AGE] year-old male admitted [DATE] with
diagnoses that included: left hip fracture, Hyperlipidemia (high cholesterol) cognitive communication deficit,
blindness right eye, hearing loss right ear and pressure ulcer. There was no entry on the face sheet to
include an updated diagnosis for COVID-19.
Review of Resident #4's care plan with a last revie date of 12/1/2023 reflected no problem/focus area
related to a diagnosis of a Covid infection as well as no goals or interventions for care.
Review of Resident #5's face sheet dated 12/21/2023 reflected an [AGE] year-old male admitted to the
facility on [DATE] with diagnoses that included: muscle wasting and atrophy, Anemia, Hyperlipidemia,
repeated falls and Dementia. There was no entry on the face sheet to include an updated diagnosis for
COVID-19.
Review of Resident #5's care plan with a last review date of 11/27/2023 reflected no problem/focus area
related to a diagnosis of a Covid infection as well as no goals or interventions for care.
Review of Resident #6's face sheet dated 12/21/2023 reflected a [AGE] year-old female admitted on [DATE]
with diagnoses that included: Cerebral Ischemia (impaired blood flow to the brain), lack of coordination,
cognitive communication deficit, Hypertension (high blood pressure) and Osteoarthritis of the Knee. There
was no entry on the face sheet to include an updated diagnosis for COVID-19.
Review of Resident #6's care plan with a last review date oof 12/8/2023 reflected no problem/focus area
related to a diagnosis of a Covid infection as well as no goals or interventions for care.
Review of Resident #7's face sheet dated 12/21/2023 reflected an [AGE] year-old male admitted on [DATE]
with diagnoses that included Alzheimer's Disease, Acute Cystitis (bladder infection), Cellulitis of right lower
limb (bacterial skin infection), Dementia (progressive memory loss) and Hypertension (high blood
pressure). There was no entry on the face sheet to include an updated diagnosis for COVID-19.
900000000ooooooooo9
Review of Resident #7's care plan with a last review date of 12/8/2023 reflected no problem/focus area
related to a diagnosis of a Covid infection as well as no goals or interventions for care.
Review of Resident #8's face sheet dated 12/21/2023 reflected a [AGE] year-old female admitted on [DATE]
with diagnoses that included Cerebral Infarction (stroke), Sepsis (systemic infection), Acute Respiratory
Failure (breathing disorder), Vascular Dementia (memory loss related to impaired brain circulation), and
Type 2 Diabetes (blood sugar regulation disorder). There was no entry on the face sheet to include an
updated diagnosis for COVID-19.
Review of Resident #8's care plan with a last revie date of 11/21/2023 reflected no problem/focus area
related to a diagnosis of a Covid infection as well as no goals or interventions for care.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676364
If continuation sheet
Page 2 of 3
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
676364
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/21/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Morada Temple
4312 S 31st St
Temple, TX 76502
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an interview on 12/15/2023 at 4:15 pm, the MDS Nurse stated the AD asked her to complete an
audit that day, 12/15/2023 of all the care plans of the residents that had a COVID infection during their last
outbreak in November 2023. She stated she reviewed all eight care plans on 12/15/2023 and none of them
had been updated to include any problems/focus areas/interventions in any of the care plans for their
recent COVID infections or interventions for care. She stated she used to be responsible for updating all of
the care plans after a change in condition, but now it was done by discipline and the Infection Control Nurse
was responsible for updating care plans after infections like COVID. She stated updating the care plans was
important because it wa a road map of care for each resident. She further stated the Infection Control
Nurse had been out of the facility with a family situation and no one knew the care plans had not been
updated. She stated she would be going in today and updating all the care plans to reflect the residents had
COVID, even though the outbreak was over, so the records would be accurate.
During an interview on 12/15/2023 at 2:53 pm, the DON stated the Infection Control Nurse should have
updated the residents' care plans after their change in condition to reflect their Covid infections. She stated
care plans are important because they are the care and outline of everything this resident might need and
how we are going to do that; get it done. She further stated she expected care plans to be updated for
COVID infections and include isolation precautions and PPE restrictions or requirements should be on the
care plan, and this assigns responsibility and action. She stated ultimately a full staff DON would be
responsible for making sure care plans are updated and I'm only an interim DON; I'm still in training and
learning. She stated she has been at the facility since June 2023 and is not the Infection Control Nurse's
boss. She stated, I'm more of a peer and not responsible for making sure it got done.
During an interview on 12/15/2023 at 3:19 pm, the AD stated the Infection Control Nurse (who is also the
ADON) was responsible for updated resident care plans. She stated a COVID infection would be a change
in condition and the care plans should have been updated. She stated that ultimately it falls to the AD to be
responsible for making sure care plans were updated. She stated that the steps would be that care plans
are updated by the proper discipline; in this case it would be nursing, and the DON would oversee that and
be responsible; then the AD would be responsible for making sure the DON followed up. She stated care
plans are important because the facility used care plans for information to prevent other things from
occurring. She stated, It's the story of what's going on with the resident. She stated when care plans are not
updated and not followed additional things could occur. She stated, By not following our plan, an infection
could spread. The care plan ensures they are taking care of the resident's needs. She further stated the
Infection Control Nurse had been out with a family emergency and she did not realize the care plans were
not being updated.
Record Review of facility policy Goals and Objectives, Care Plans dated revised April 2009, reflected the
policy statement Care plans shall incorporate goals and objectives that lead to the resident's highest
obtainable level of independence. Under the Policy Interpretation and Implementation title it reflected: 1.
Care plan goals and objectives are defined as the desired outcome for a specific resident problem. 4. Goals
and objectives are entered on the resident's care plan so that all disciplines have access to such
information and are able to report whether the desired outcomes are being achieved. 5. Goals and
objectives are reviewed: a. when there has been a significant change in the resident's condition.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676364
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FAQ · About this visit
Common questions about this visit
What happened during the December 21, 2023 survey of MORADA TEMPLE?
This was a inspection survey of MORADA TEMPLE on December 21, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MORADA TEMPLE on December 21, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.