Health inspection·January 16, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, record review and observation, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #100), reviewed for care plans. The facility failed to implement and ensure Resident #100 had 2 beveled mats on floor as care planned dated 10/25/24. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs. The Findings included: Record review of Resident #100's face sheet dated 1/15/25 reflected a [AGE] year-old-male with an original admission date of 3/05/22. Diagnoses included Dementia (decline in cognitive abilities that affects a person's ability to perform everyday activities), hypertension (high blood pressure), and unsteadiness on feet. Record review of Resident #100's care plan dated 10/25/24 stated Resident #100 was at risk for falls due to unsteadiness on feet. Interventions included 2 beveled mats. Record review of Resident #100's annual MDS dated [DATE] reflected a BIM score of 2 (severe cognitive impairment), utilized a wheelchair, and required partial/moderate assistance with sitting/standing and chair/bed transfers. During an observation on 01/14/25 at 02:55 PM Resident was asleep in bed with one floor mat noted to right side of the bed. During an observation on 01/15/25 at 01:50 PM Resident was in bed. One floor mat noted to right side of the bed. In an interview on 01/15/25 at 01:52 PM LVN C stated Resident #100 should have had two floor mats at bedside for fall precautions as Resident #100 had a history of sliding himself off the bed. LVN C stated she was not sure why Resident #100 did not have two floor mats but would immediately get another floor mat to have at Resident #100's bedside. LVN C stated Resident #100 needed two floor mats (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 4 Event ID: 455455 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 455455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meridian Care of Alice 218 219 N King St Alice, TX 78332 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)