Health inspection·February 22, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 a comprehensive person-centered careplan describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 14 residents, (Resident #10 and #53), in that: -Resident #10 was not care planned for nutritional deficits adequately, functional status, bladder and bowel status, heart related disease and respiratory failure. -Resident #53 was not care planned for foley catheter use and dialysis. These failures placed residents at risk of not receiving adequate medical care in a timely manner. Findings include: Resident #10 Record Review of Resident # 10's Face Sheet revealed a [AGE] year old female who had an initial admission date of 11/6/2023 and a readmission date of 1/17/2024 with diagnoses of Other mechanical complications of other electronic device (Complications from implanted cardiac device), subsequent encounter, Other specified pleural conditions (Punctured lung), encounter for surgical aftercare following surgery on the respiratory system (At facility for rehab after surgery), Acute respiratory failure with hypoxia (not enough oxygen), Unspecified severe protein-calorie malnutrition (Not enough dietary intake of protein), Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side (Right sided weakness following stroke). Record Review of Resident #10's MDS (Minimum Data Set) dated 1/23/2024 revealed a BIMS score of 15 out of 15 indicating resident was cognitively intact. Resident was dependent on toileting, showering and bathing, lower body dressing, rolling to left and right, lying to sitting, sitting to lying, chair to bed transfers, toilet transfer, car transfer. Resident substantial maximum assist with walking 150 feet, oral hygiene, upper body dressing. Resident incontinent of bladder and frequently incontinent of bowel. Diagnoses: Anemia (Low blood count), Coronary Artery Disease (Disease of the hearts blood vessels), Hypertension (High blood pressure), Hyperlipidemia (High blood fats), Cerebrovascular Accident (Loss of blood to part of the brain) and Hemiplegia or Hemiparesis (Weakness on one side), Malnutrition (not eating enough), Respiratory failure (Difficulty breathing). Record Review of Resident #10's Care Plan dated 11/15/2023 last review date 12/11/2023 read in part . Advance Directive: Resident #10 has advance directive for full code status .Skin: Resident is at Page 1 of 3 676434 676434 02/22/2024 North Houston Transitional Care 9814 Grant Rd Houston, TX 77070

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some risk for skin breakdown related to Braden Risk Score revision on 11/15/2023 . Nutritional deficits, functional status, bladder and bowel status, heart related disease and respiratory failure were not addressed. Record Review of Resident #10's physician orders read in part . Admit for skilled services .1/18/2-24 .Med Pass 2.0 three times a day for nutrition supplement .1/29/2024 Regular diets, regular texture, thin liquids .1/18/2024 . Interview on 2/22/2024 at 2:45 pm with the DON (Director Of Nursing) she said the purpose of a care plan was to provide care for the patient. She said nurses used the care plan in conjunction with orders to provide care for the patient. She said the IDT (Interdisciplinary team) team was responsible for creating and updating the care plan by discussing and updating the care plan in the areas they specialized in. She said the IDT team consisted of the DON, ADON, MDS, Dietary, SW, Activities and Therapy. She said there were discussions from the care plan meetings and other meetings at the facility that went into creation of the care plan. She said if the care plan was not updated it could have impacted patient care. Interview on 2/22/2024 at 3:05pm with the ADON (Assistant Director of Nursing) she said if there were no care plan, or the care plan was not updated it could have impacted general care and there could have been potential mishaps with patient care. She said there could have been gray areas that could have impacted the quality of patient care. Resident #53 Record review of Resident #53's face sheet, dated 02/22/2024, revealed a [AGE] year-old male who was admitted into the facility on [DATE] and diagnosed with stage 4 pressure ulcer on left buttock, end stage renal disease, and personal history of malignant neoplasm of prostate. Record review of Resident #53's MDS, dated [DATE], revealed the resident was documented to have a BIMS score of 14, indicating his cognition was intact, and the resident was marked for having an indwelling catheter. Record review of Resident #53's physician's orders revealed the resident was ordered, since 01/24/2024, to receive foley catheter care, including changing out the foley catheter and foley bag monthly and as needed. The resident was also ordered to receive dialysis treatments three times a week starting 01/24/2024. Record review of Resident #53's care plan revealed resident's need for dialysis and the use of an indwelling foley catheter were not mentioned or documented. Interview with Resident #53 on 02/21/24 at 02:58 PM, he stated he has a foley catheter and last had his foley catheter changed out early in the morning by an LVN before his dialysis appointment . Interview with the Interim DON on 02/22/2024 at 4:07PM, she stated treatments, such as dialysis, and the use of an indwelling catheter needs to be care planned because it is a need that the resident has. She stated the care plan was used for nurses to references and get a picture of the resident. She stated the risk of not having complete comprehensive care plan was the provision of incomplete care to residents due to staff having limited information outside of orders. 676434 Page 2 of 3 676434 02/22/2024 North Houston Transitional Care 9814 Grant Rd Houston, TX 77070

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of facilities policy titled, Care Plans, Comprehensive Person-Centered dated March 2022 read in part . A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the psychosocial and functional needs The comprehensive person-centered care plan should be developed within 7 days of the completion of the required MDS assessment and should be completed within 21 days of admission describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental and psychosocial wellbeing that the resident desires or that is possible .interventions should address the underlying sources of the problem. . 676434 Page 3 of 3