Health inspection·April 19, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for two (Resident #86 and Resident #87) of five residents reviewed for baseline care plans. The facility failed to complete Resident #86's and Resident #87's baseline care plan within 48 hours of admission that included the minimum required healthcare information including physician orders, dietary orders, therapy services, and social services. This failure placed residents at risk of not receiving effective and person-centered care. Findings included: 1. Review of Resident #86's Face Sheet, dated 04/19/23, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included a right femur neck fracture (hip fracture), type 2 diabetes mellitus (insulin resistance), hypertensive heart disease without heart failure (changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), and atrial fibrillation (an irregular and often very rapid heart rhythm). Review of Resident #86's Baseline Care Plan, dated 04/14/23, reflected it did not address therapy services. In addition, the dietary/nutritional status and social services sections were not fully completed (dietary/nutritional status was missing information including dietary preferences and dietary risks, as applicable and social services was missing informaiton including PASRR recommendations). The Baseline Care Plan was not completed until 04/18/23. 2. Review of Resident #87's Face Sheet, dated 04/19/23, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), anemia (a lack of red blood cells), hypothyroidism (low activity of the thyroid gland), and hyperlipidemia (a condition in which there are high levels of fat particles or lipids in the blood). Review of #87's Baseline Care Plan, dated 04/17/23, reflected it did not address therapy services or social services. In addition, the dietary/nutritional status section was not fully completed (dietary preferences and dietary risks, as applicable). The Baseline Care Plan was not completed until 04/18/23. Page 1 of 2 676410 676410 04/19/2023 Pure Health Transitional Care at Texas Health Pres 8200 Walnut Hill Lane Main 5 Dallas, TX 75231

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a telephone interview with the MDS Coordinator on 04/18/23 at 1:45PM, she stated she was responsible for ensuring baseline care plans were completed upon resident admissions. She stated upon a resident's admission, she generated a blank baseline care plan in the resident's electronic health record. Each department (dietary, therapy, social services, etc.) was then responsible for completing their portion of the baseline care plan. Upon completion, she and the DON reviewed the baseline care plan and saved it as completed. The baseline care plan was then provided to the resident. During an interview with the DON on 04/18/23 at 1:30PM, she stated baseline care plans were to be completed within 48 hours of a resident's admission. She stated the MDS Coordinator generated a blank baseline care plan in the resident's electronic health record, and then each appropriate department completed their portion of the baseline care plan. Upon completion, the baseline care plans were reviewed by herself and/or the MDS Coordinator and provided to the resident. The DON stated because this was a short-term facility, there was not a risk to residents if the baseline care plan was not completed within the regulatory guidelines. She stated the resident's care was implemented based off items such as the resident's hospital orders and assessments. Review of the facility's Care Plans - Baseline policy, dated 03/22, reflected, .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . and .1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable . 676410 Page 2 of 2