Health inspection·January 4, 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 7 residents (Residents #1, #2, and #3) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #1's care plan included Hypertensive Heart Failure. 2. The facility failed to ensure Resident #2's care plan included Hypertension. 3. The facility failed to ensure Resident #3's care plan included Hypertension. These failures could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #1's face sheet dated 01/04/24, revealed a [AGE] year-old female, with an initial admission date of 02/12/22, and a readmission date of 04/20/23, and a diagnosis of Alzheimer's Disease (disease in brain that controls thought, memory, and language), Dysphagia (difficulty swallowing), Hyperlipidemia (high level of fat particles in the blood), Hypertensive Heart Disease (problems with your heart due to untreated high blood pressure), Cerebral Infarction (disrupted blood flow to the brain), Persistent Mood (Affective) Disorder (depression that lasts for several years), Difficulty in Walking, Muscle Weakness, and Unspecified Lack of Coordination. Record review of Resident #1's care plan, dated 11/29/23, did not address her diagnosis of Hypertensive Heart Failure. Record review of Resident #2's face sheet dated 01/04/24, revealed a [AGE] year-old female, with an admission date of 01/11/22, and a diagnosis of Malignant Neoplasm of Brain, Epilepsy, Other Symbolic Disfunctions, Hyperlipidemia, Essential Hypertension, and Long-Term use of Antithrombotic/Antiplatelets. Record review of Resident #2's care plan, dated 11/29/22, did not address her diagnosis of Essential Hypertension. Record review of Resident #3's face sheet dated 01/04/24, revealed an [AGE] year-old female, with an admission date of 10/04/22, and a diagnosis of Lymphedema, Anemia, Hypothyroidism, Hyperlipidemia, Essential Hypertension, Cerebral Infarction, and History of other Venous Thrombosis and Embolism. Page 1 of 2 745006 745006 01/04/2024 Five Points Nursing and Rehabilitation 1901 N Hampton Rd Desoto, TX 75115

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #3's care plan, dated 12/15/23, did not address her diagnosis of Essential Hypertension. In an interview on 01/04/24 at 4:14 PM, MDS Nurse stated she had only worked at the facility since September 2023. She stated her responsibilities included assessments and care plans. She stated she was the one that reviewed Resident #1's care plan around 11/28/23. She stated it was due for a review. MDS Nurse stated during the review one of her duties was to ensure there were no new issues that need to be care planned. She stated she was not sure why the hypertensive heart disease was not addressed on Resident #1's care plan. She stated that before the care plan was completed certain staff like the social worker, a nurse, and dietary review the care plan. MDS Nurse stated even though they review it, her signature is the only one seen on the care plan, and she cannot recall which nurse reviewed Resident #1's care plan before it was completed. MDS Nurse stated the risk of not addressing a diagnosis is a resident could go into heart failure or hypertensive mode if the care plan was not followed. In a follow-up interview on 01/04/24 at 5:35 PM, MDS Nurse stated she started working at the facility last September, and she was not sure why certain care plans did not address all diagnosis. She stated she had been trying to fix the care plans. She stated the facility started their own audit process for care plans. She stated hopefully it would take just one month to get the issue corrected. In an interview on 01/04/24 at 5:39 PM, DON stated she and the ADONs, two wound care nurses, and MDS Nurse started an audit to correct the care plans, to ensure they address all diagnoses. She stated she guaranteed the audit would be completed by close of business tomorrow, 01/05/24. She stated that several staff members signed off on the care plans, but all staff do not sign the care plan or document in the system who reviewed the care plans. DON stated she was not aware the care plans for Resident #2 and Resident #3 did not address hypertension until today. DON stated she started printing the diagnoses sheets to review for all residents. DON stated the risk of not addressing a diagnosis on a care plan is that diagnosis not being addressed, which could have affected a resident by mistreatment or missed interventions. In an interview on 01/04/24 at 5:47 PM, Administrator stated he understood the need to ensure all care plans were comprehensive. He stated all diagnosis should be addressed for the resident and for the best care. Record review of the facility's undated policy titled, Comprehensive Care Planning, revealed the following: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. 745006 Page 2 of 2