F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to review and revise the person-centered care
plan to reflect the current condition for 1 resident (Resident #30) of 18 residents reviewed for care plan
accuracy.
The facility failed to ensure Resident #30's care plan was updated to reflect her current feeding status of
puree diet.
This failure could place residents at risk of not receiving appropriate interventions to meet their current
needs.
Findings include:
Record review of Resident #30's face sheet dated 11/09/23 reflected an [AGE] year-old female who was
admitted to the facility on [DATE]. Her diagnoses included respiratory failure, shortness of breath, chronic
obstructive pulmonary disease, muscle weakness, anxiety disorder.
Record review of Resident #30's admission MDS dated [DATE], section C revealed a BIMS score of 15
which indicated the resident was cognitively intact.
Record review of Resident #30's care plan dated 09/27/23 reflected that Resident #30 was care planned for
tube feeding related to a swallowing problem, and weight loss. Date initiated was 09/27/23. The goal
reflected the resident will maintain adequate nutritional and hydration status. The care plan did not include
the information on her diet of puree texture.
Record review of Resident #30's physician's order dated 10/04/23 revealed an order - Regular diet Pureed
texture, Regular consistency, thin. puree with gravy and broth per ST Active 10/04/2023 to 11/04/2023
Observation and interview on 11/07/23 at 10:00AM, revealed Resident #30 was in her bed using her tablet.
She was alert and oriented. In an interview, she said her breakfast was good. She said she was happy that
she could eat again.
Observation and interview on 08/12/23 at 12:15AM , revealed Resident #30 was in the dining room having
lunch. Her meal was a regular, puree diet. She said her food was good and had no complaints.
In an interview with LVN D on 11/08/23 at 10:00AM, he said Resident #30 had a G-tube for her
(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 2
Event ID:
676400
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
676400
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mrc the Crossings
255 N Egret Bay Blvd
League City, TX 77573
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
medication only. He said Resident #30 was previously on G-tube feedings but the G-tube feeding was
discontinued sometime ago, and the G-tube was left for her medication.
During an interview with the MDS coordinator on 11/09/23 at 1:00PM, she said Resident #30's care plan
was done by the interdisciplinary team. She said the dietitian usually updated the care plan whenever there
were new orders.
In an interview with the Dietitian on 11/09/23 at 1:30PM, she said she wrote her notes on Resident #30's
clinical record. She said she should have updated the care plan to reflect her diet change from tube feeding
to oral puree diet. She said not updating the care plan could result in Resident #30 not being served her
meals. She said she would update Resident #30's care plan to reflect her puree diet.
Record review of facility's policy on care plan dated 2001 updated March 2022 read in part-policy statement
A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet
the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
1
The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative,
develops and implements a comprehensive, person-centered care plan for each resident.
.9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful
consideration of the relationship between the resident's problem areas and their causes, and relevant
clinical decision making.
10.
When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or
triggers.
11.
Assessments of residents are ongoing and care plans are revised as information about the residents and
the residents' conditions change.
12.
The interdisciplinary team reviews and updates the care plan:
a.
when there has been a significant change in the resident's condition.
b.
when the desired outcome is not met;
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676400
If continuation sheet
Page 2 of 2
