Health inspection·November 21, 2024

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 observation, interview, and record review the facility failed to ensure the resident's Comprehensive Care Plan was developed and Implemented for 1 (CR #1) of 4 residents reviewed for care plans. The facility failed to address CR#1's wound care and adls needs in the care plan. This failure could place residents at risk of not having necessary care and services provided to address the residents individual needs. Findings include: Record review of CR #1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, cyst of pancreas, cognitive communication disorder, Type 2 Diabetes [NAME] Without Complications and Acquired Absence of Right Leg Below Knee. Review of CR #1's Quarterly MDS (Minimum Data Set) dated 10/07/24, section C revealed a BIMS (Brief Interview for Mental Status) score of 14. Section G regarding resident's Activities of Daily Living (ADL) Assistance revealed resident needs supervision and two persons assisting with bed mobility, transferring and toilet use. It also revealed resident required, two-person assistance with dressing, and personal hygiene. Section M identified CR #1 at risk of developing pressure ulcers/injuries and did not have ulcers, wound or skin problems at time of assessment. Record review of CR #1's care plan dated 10/15/2024 revealed CR#1 was not care planned for wound care nor the resident's ADL Self Care Performance Deficit. Record review of Physician order dated 11/06/2024 revealed that the facility received a phone order to treat CR#1 left medial heal due to a pressure injury. The order directed the facility to irrigate, or cleanse wound bed with normal saline, nexodyn solution or wound cleanser. Further record review of the care plan for CR #1 revealed no information regarding left medial heal due to a pressure injury identified on 11-6-2024. Interview with LVN-A On 11/21/2024 at 3:00pm, she said that everyone works together to complete a resident's care plan. She said when there was a change of condition dealing with a resident skin assessment the wound care nurse was responsible for getting that information to the DON. She said that the resident's care plan should be updated immediately so that the resident's care would be not Page 1 of 3 676381 676381 11/21/2024 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few compromised. She said that the risk of not having the care plan updated immediately was that the resident may have not received adequate care. Interview with LVN-B- on 11/21/2024 at 3:22pm, she said she was updating the resident's care plan right away. She said the care plan should be updated with in 24hrs to ensure that the resident was getting proper care. She said if the care plan was not updated right away then the resident runs the risk of not being properly cared for if they have skin issues. Interview with DON on 11/21/2024 at 3:40pm, she was asked why CR#1 care plan wasn't updated for wound care and said the wound care nurse's job to update the care plan of a resident that develops skin care issues and that the nurse must inform the DON. She said the DON's job was to ensure the care plan was updated and being implemented. She said the care plan should be updated a least with in 24hrs after the skin care issue has been discovered. She said the risk of not updating the care plan right away is that the resident may not receive proper care. Interview with Administrator on 11/21/24 at 3:45pm, he was asked why didn't CR#1 have an updated care plan and he stated the wound care nurse was responsible for updating a resident's care plan if a resident develops a skin care issue. He said that the care plan should be updated within 24 hours after the discovery of the skin care issue. He said that the wound care nurse should report the skin care issue to the DON and that the DON was responsible for making sure the care plan was followed. He said the risk of the care plan not being updated after the discovery of a resident skin issue is that the resident was not receiving proper care. Record review of facility's Comprehensive Care Plan policy dated April 2023 revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplina1y team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. d. The resid1mt's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate. 676381 Page 2 of 3 676381 11/21/2024 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 7. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 676381 Page 3 of 3