Health inspection·January 10, 2025

F 0641 Ensure each resident receives an accurate assessment. 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 have assessments that accurately reflected the status for one (Resident #1) of five residents reviewed for assessment accuracy. Residents Affected - Few The facility failed to ensure Resident #1's transfer status was accurate in her MDS as it did not reflect she required a mechanical lift. This deficient practice could result in errors in care and treatment. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including displaced comminuted fracture of shaft of right femur (thigh bone), unsteadiness on feet, and muscle wasting and atrophy (wasting away). Review of Resident #1's admission MDS assessment, dated 11/04/24, reflected a BIMS score of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities) reflected she was dependent with transfers, utilized a manual wheelchair, and did not require a mechanical lift. Review of Resident #1's admission care plan, dated 11/06/24, reflected she had ADL self-care performance deficit related to impaired mobility with an intervention of requiring total assistance with transfers. Review of Resident #1's Daily Skilled with Self-Care Mobility Assessment, dated 01/09/25, reflected Limited ROM requires x2 persons assist to transfer bed to chair, bed and into the wheelchair. Mechanical lift to transfer [sic]. During an interview on 01/10/25 at 9:34 AM, LVN A stated Resident #1 required a mechanical lift transfer with two staff members assistance for all transfers as she was unable to bear weight. During an interview on 01/10/25 at 12:21 PM, the DON stated it was the nursing department's responsibility to ensure the MDS and care plan matched the residents' transfer status. She stated it was her expectation that they were up to date, matched, and staff knew how to properly transfer each resident. She stated it was important to ensure they were providing the best care to the residents. She stated a negative outcome of the assessments not matching would depend on the situation, but it was important for safety reasons. Review of the facility's Nursing Services - ADLs Policy, revised 05/2007, reflected the following: Page 1 of 3 676373 676373 01/10/2025 Park Manor Bee Cave 14058 Bee Caves Parkway, Bldg B Bee Cave, TX 78738

F 0641 Level of Harm - Minimal harm or potential for actual harm Each resident is assessed for their ability to perform ADLs and the assistance needed, and a plan of care is developed and interventions are implemented based on their needs, goals of care and preferences. Each resident receives adequate supervision and assistive devices as needed. Residents Affected - Few 676373 Page 2 of 3 676373 01/10/2025 Park Manor Bee Cave 14058 Bee Caves Parkway, Bldg B Bee Cave, TX 78738

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure Resident #1's transfer status was accurate in her care plan as it did not reflect she required a mechanical lift. This deficient practice could result in errors in care and treatment. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including displaced comminuted fracture of shaft of right femur (thigh bone), unsteadiness on feet, and muscle wasting and atrophy (wasting away). Review of Resident #1's admission MDS assessment, dated 11/04/24, reflected a BIMS score of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities) reflected she was dependent with transfers, utilized a manual wheelchair, and did not require a mechanical lift. Review of Resident #1's admission care plan, dated 11/06/24, reflected she had ADL self-care performance deficit related to impaired mobility with an intervention of requiring total assistance with transfers. Review of Resident #1's Daily Skilled with Self-Care Mobility Assessment, dated 01/09/25, reflected Limited ROM requires x2 persons assist to transfer bed to chair, bed and into the wheelchair. Mechanical lift to transfer [sic]. During an interview on 01/10/25 at 9:34 AM, LVN A stated Resident #1 required a mechanical lift transfer with two staff members assistance for all transfers as she was unable to bear weight. During an interview on 01/10/25 at 12:21 PM, the DON stated it was the nursing department's responsibility to ensure the MDS and care plan matched the residents' transfer status. She stated it was her expectation that they were up to date, matched, and staff knew how to properly transfer each resident. She stated it was important to ensure they were providing the best care to the residents. She stated a negative outcome of the assessments not matching would depend on the situation, but it was important for safety reasons. Review of the facility's Nursing Services - ADLs Policy, revised 05/2007, reflected the following: Each resident is assessed for their ability to perform ADLs and the assistance needed, and a plan of care is developed and interventions are implemented based on their needs, goals of care and preferences. Each resident receives adequate supervision and assistive devices as needed. 676373 Page 3 of 3