Health inspection·November 5, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one (Resident #1) of three residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #1. This deficient practice could place residents at risk of not having individualized need met, a delay in services, sustaining injuries, and not receiving adequate care. Findings included: 1. Record review of Resident #1's Face Sheet, dated 11/05/2024, reflected a -[AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses of sepsis, unspecified organism ( a medical condition where the body has an extreme response to an infection, but the type of organism causing the infection was unknown), type 2 diabetes mellitus with foot ulcer ( when the body does not respond properly to insulin, a hormone that helps move sugar from the blood into the cells. High blood sugar levels from diabetes can damage nerves and blood vessels in the feet, leading to foot ulcers), essential hypertension ( a condition of high blood pressure that is not caused by another medical condition), hiccup( repeated spasms or sudden movements in the diaphragm [has a major part in breathing] that a person cannot control), nausea and vomiting ( feeling sickness to your stomach causes eject matter from your stomach through your mouth), and local infection of the skin and subcutaneous tissue, unspecified ( a common condition that occurs when harmful bacteria or fungi enter the skin and cause inflammation and tissue damage). Record review of Resident #1's admission MDS Assessment, dated 06/26/2024, reflected Resident #1 had a BIMS score of 15 indicating his cognition was intact. Resident #1 was assessed to be dependent on staff for the following ADLs: personal hygiene, dressing, showers, toileting hygiene, chair to bed, and bed to chair transfers. Resident #1 required partial/moderate assistance ( helper does less than half the effort) with showers and repositioning in bed. He required substantial/maximal assistance (help does more than half the effort) with transfers, toileting hygiene and lower body dressing. Resident #1 required set up assistance with oral hygiene and upper body dressing. Resident #1 required set up or clean up assistance with personal hygiene. Resident #1 was diagnosed with medically complex conditions ( a chronic health issue that affect multiple organs or systems in the body, and often requires ongoing medical attention) Page 1 of 2 676437 676437 11/05/2024 Accel at College Station 1500 Medical Avenue College Station, TX 77845

F 0655 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's Baseline Care Plan, dated 06/24/2024, reflected Resident #1's nausea/vomiting on the was not documented. ( Resident #1 had an admitting diagnosis of nausea/vomiting ). Section O: Diabetic Alert : medications and diet were not documented. Section R : Infection Alert was not documented ( Resident #1 was admitted with sepsis and with a diagnosis of local infection of the skin). Signed by LVN A. Residents Affected - Few In an interview on 11/5/2024 at 2:30 PM, MDS Coordinator B stated a baseline care plan was to be completed within 48 hours of admission. She stated if a resident has an admitting diagnosis of infection or diabetes all of the information related to these diagnoses was expected to be documented on the baseline care plan. MDS Coordinator B stated it would be difficult for the CNAs to know what type of care a resident may need if baseline was not completed in its entirety. She stated the information given to the residents in the computer system came from the baseline care plan. MDS Coordinator stated it was the DONs responsibility to complete the baseline care plan. The MDS Coordinator stated after reviewing Resident #1's baseline care plan, it was not a completed document. She stated there were areas on the baseline care plan not documented such as diabetes and infection alert. In an interview on 11/5/2024 at 2:45 PM, requested baseline care plan policy from the DON. In an interview on 11/5/2024 at 3:30 PM, requested baseline care plan policy from the Administrator. In an interview on 11/5/2024 at 3:45 PM, the DON stated she was responsible for baseline care plans. She stated if a resident was admitted after 5:00 PM on a Friday the nurse supervisor would complete the baseline care plan and she would review it on the following Monday to ensure the baseline care plan was completed and accurate. The DON stated if a resident was admitted with diagnoses of diabetes type 2 with a foot ulcer and had sepsis infection, the information of these two diagnoses was expected to be on the baseline care plan. She did not respond when asked if a resident had a diagnosis of type 2 diabetes with foot ulcer and an admitting diagnosis of sepsis with unspecified organism was expected to be documented on the baseline care plan. Requested a baseline care plan. The DON stated she was responsible at all times for baseline care plan if a resident was admitted during the week. The DON did not respond to the question if she was not in the facility during the week who would be responsible for the baseline care plan. In an interview on 11/5/2024 at 4:15 PM, LVN C stated the DON was responsible for the baseline care plans. She stated it was very unusual for a resident to be admitted after 5:00 PM. LVN C stated if a resident was admitted to the facility it was the DON responsibility to complete the baseline care plan. LVN C stated if the DON was not in the facility the nurse supervisor would complete the baseline care plan. She stated there had been times the DON was not available to complete the baseline care plan. The facility policy of baseline care plan was not provided at time of exit on 11/5/2024. 676437 Page 2 of 2