Health inspection·August 21, 2025

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 interviews and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans. The facility did not include Resident #1's mechanically altered diet (modified texture and consistency of food and liquids such as mechanical soft or purred diet) on her care plan. This failure could place residents at risk for not receiving a safe and appropriate care.The findings include: Record review of Resident #1's face sheet, dated 08/21/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 08/16/25. Resident #1 had diagnoses which included: fistula of vagina to large intestine (abnormal connection that allows gas, stool and other contents from the large intestine to leak into the vagina), malignant neoplasm (cancer) of unspecified ovary, and anorexia nervosa (eating disorder), unspecified. Record review of Resident #1's Medicare 5 day Minimum Data Set assessment, dated 07/04/25, revealed Resident #1 had a BIMS score of 11, which indicated she was moderately cognitively impaired. Resident #1's MDS indicated she was on a mechanically altered diet that required a change in texture of food or liquids on admission and while a resident at the facility. Record review of Resident #1's initial nursing evaluation with an effective date of 07/02/25 reflected she was on a mechanically altered diet. Record review of Resident #1's order summary report reflected she had an order for mechanical soft texture and regular liquids consistency from 07/02/25 until 07/25/25 when it was discontinued and was upgraded to a regular texture and regular liquid consistency diet from 07/25/25 until 08/11/25. Resident #1 had an order for pureed texture and regular liquids started 08/11/25 until it was discontinued on 08/16/25. Record review of Resident #1's initial baseline care plan dated 07/02/25 reflected her diet ordered was .mech [mechanical] soft, thin liquids and was marked as Yes under question that asked, Mechanically Altered? Record review of Resident #1's nursing noted reflected a note dated 08/11/25 that stated Resident #1's responsible party had notified RN A of Resident #1's request to change her diet texture to puree. Record review of Resident #1's closed comprehensive care plan, with a closed date of 08/18/25 did not reflect Resident #1's mechanically altered diet or food texture and liquid consistency. During an interview with MDS Nurse B on 08/21/25 at 3:05pm she stated she was responsible for completing the comprehensive care plan for Resident #1. MDS Nurse B stated she had reviewed Resident #1's care plan and it did not include her diet. MDS Nurse B stated it was best to include residents diets and altered texture diets on their care plans and stated she should have put a diet on Resident #1's care plan. MDS Nurse B stated she did not have a valid reason as to why Resident #1's diet was not include don her care plan. MDS Nurse B stated it was initially important to include diets on residents care plans to notify staff that they are on a mechanically altered diet. MDS Nurse B stated the care plans had to be signed Page 1 of 2 676391 676391 08/21/2025 Windsor Calallen 4162 Wildcat Dr Corpus Christi, TX 78410

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few by an RN but she was not sure about how often they were being monitored. MDS Nurse B stated she had been trained over developing a care plan and what it should include., MDS Nurse B did not recall an exact date of her last training but stated they had calls every Friday with their corporate team where they stressed the importance of care planning. MDS Nurse B was asked how not including a residents diet on their care plan could negatively impact them and stated she understood the importance of it but stated there were plenty of other areas that staff could find that information that was accurate, good, safe and quick for their diets in question. During an interview on 08/21/25 at 3:25pm with the Regional MDS Nurse, she stated every Friday she completed education calls. The Regional MDS Nurse stated on 05/05/25 she was at the facility and provided a training over care areas that had to be care planned including nutrition and where to care plan diets. The Regional MDS Nurse stated MDS Nurse B had received the training. The Regional MDS Nurse stated she was unable to find any documentation of the education that was provided on 05/05/25. During an interview with the DON on 08/21/25 at 3:42pm she stated MDS Nurse B was responsible for completing Resident #1's care plan. The DON stated care plans should include the resident's diets and stated she had reviewed Resident #1's care plan and it did not include her diet. The DON stated she did not know why Resident #1s care plan did not include her diet. The DON stated it was important to include resident's diets on their care plans so that everyone could be aware of it. The DON stated she reviewed and monitored the care plans to ensure they had all required information. The DON stated care plans should be monitored daily and stated she performed monthly audits on everything and stated any new changes should have been updated on the care plans. The DON stated her and MDS Nurse B had both been trained by the Regional MDS Nurse over developing a care plan and what should be included and stated her last training was on 07/15/25 and MDS Nurse B last training was on 05/05/25. The DON stated they did not have any documentation for those trainings. The DON stated not including a resident diet on their care plan could negatively impact them because they could miss a diet texture. During a continued interview on 08/21/25 at 3:42pm with the DON she stated she did not have any documentation to provide for the training her and MDS Nurse B had received over care plans by the Regional MDS nurse on 05/05/25 and 07/15/25. At this time the DON provided an Inservice she had started on 08/21/25 that included the DON and MDS Nurse B and covered, completing care plans accurately and reviewing [and] updating daily [with] any new orders, changes in condition/ADLS Record review of facility policy titled, Comprehensive Care Plans with an implementation date of 10/24/22 included the following verbiage, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that 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. and 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. 676391 Page 2 of 2