Health inspection·June 22, 2023

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 develop and implement a person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #1) of 5 residents reviewed for comprehensive care plans. Resident #1 was not care planned for tube feeding. This deficient practice could place residents at risk for not receiving appropriate care and services. Findings Included: Observation on 06/22/2023 at 5:22 p.m. revealed Resident #1 was being fed via her G-tube. Record review of Resident #1's Face Sheet, dated 06/22/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included heart failure, gastrostomy status (an artificial external opening into the stomach for nutritional support), dietary folate deficiency anemia (Vitamin B9 deficiency), hypothyroidism (to little thyroid hormone) and vitamin deficiency. Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 3 out of 15 indicating severe cognitive impairment. Further review revealed Resident #1 required two-person assist with toileting and bathing, and one-person assist with feeding. Resident #1's Nutritional Approaches section reflected a feeding tube. Record review of Resident #1's orders, dated 06/22/2023, reflected in part . cleanse G Tube site with NS, pat dry, apply drain sponge, and secure with tape .elevate hospital bed 30-45 degrees at all times during internal feeding and for 30 minutes after feeding has completed .Jevity 1.5 cal per feeding pump @ 75ml/hr x 16hrs (4pm-8am), free water flush 140ml Q 4hr bowel rest, pump off 8am-4pm daily every shift related to gastrostomy status. Record review of Resident #1's Care Plan, dated 05/08/2023, revealed it did not reflect Resident #1's need for tube feeding. In an interview on 06/22/2023 at 5:50 p.m., the DON said she and the ADON were responsible for completing care plans. She said Resident #1's need for tube feeding was not documented on the resident's care plan but should have been included. She said it was not added on the care plan because the (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: 676396 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 676396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE S.P.J.S.T. Rest Home 3 248 Wisteria Lane El Campo, TX 77437 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)