F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure residents received treatment and care in
accordance with professional standards of practice, the comprehensive person-centered care plan, and the
resident's choices for 1 of 4 residents (Resident #1) reviewed for quality of care.
Residents Affected - Few
The facility failed to ensure Resident #1's weight was recorded daily as ordered from 11/22/24 through
12/02/24.
This failure could place residents at risk of not receiving care to maintain optimum health and placing them
at risk for decline in health.
Findings included:
Review of Resident #1's face undated face sheet reflected he was admitted on [DATE] and discharged on
12/02/24.
Review of Resident #1's admission MDS assessment, dated 11/22/24, Section A (Identification Information)
reflected a [AGE] year-old male admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected
diagnoses including atrial fibrillation (an irregular heartbeat), heart failure, hypertension (high blood
pressure), cirrhosis (severe liver damage), morbid obesity, and diabetes mellitus (a condition that affects
the way the body processes blood sugar). Section C (Cognitive Patterns) reflected a BIMS score of 14
indicating intact cognition.
Review of Resident #1's care plan initiated on 09/20/24 reflected in part, Resident #1 is at risk for nutritional
and/or dehydration risk related to diabetes, congestive heart failure, and morbid obesity. Will maintain
nutritional status as evidenced by no significant weight changes through next review. Interventions included,
Monitor weights, skin report, and labs .
Review of Resident #1's physicians orders dated 11/20/24 reflected, Daily weight once a day 6:00 AM to
11:00 AM.
Review of Resident #1's recorded weights reflected 11/19/24 441.5 lbs., 11/20/24 440.5 lbs., and 11/21/24
440 lbs. There were no weights recorded for 11/22/24 through 12/02/24 (11 days).
During an interview on 12/04/24 at 12:05 PM, the NP stated it was important to monitor Resident #1's
weight because of his heart conditions , chronic edema, and morbid obesity. She stated weight changes
could indicate a change in status.
(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 2
Event ID:
455497
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
455497
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Terrace Rehabilitation
1555 Powell Avenue
Belton, TX 76513
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 12/04/24 at 3:52 PM, with LVN A, she stated the restorative aide was responsible for
weighing residents. She stated weights were monitored to help assess changes in fluid balance or
nutritional status. She stated Resident #1 had an order for daily weights, but she saw only three weights
recorded in the record. She stated she did not weigh the resident and did not know if the resident had
refused to be weighed.
Residents Affected - Few
During an interview on 12/04/24 at 3:57 PM the ADON, stated the restorative aide was responsible for daily
and weekly weights but anyone could weigh the residents. There were other staff who were responsible for
weights when the restorative aide was not in the building. She stated the weights were included on a
weekly report that went to the management team and the weights were reviewed at a meeting. She stated
changes in weight could indicate fluid imbalance or CHF.
During an interview on 12/04/24 at 4:34 PM, the DON stated the restorative aide was responsible to take
and record the weights, but all nursing staff could have taken a weight. She stated the restorative aide was
out of the facility, but she had left a message and requested a return call. She stated she found some
papers on the restorative aide's desk which included a weight for Resident #1 on 11/26/24. The DON stated
the weight was not recorded in Resident #1's electronic medical record. The DON stated it was her
expectation that physician orders be followed.
During an interview on 12/04/24 at 4:38 PM, the ADM stated it was her expectation that physician orders be
followed.
Review of the facility policy, Weighing the Resident, revised 02/26/24, reflected in part, Record all weights
per facility protocol. The policy did not address daily weights.
Review of the facility policy, Physician Orders, revised 05/05/23, reflected in part, 3. Upon admission, the
Facility has physician orders for the resident's immediate care to include but not limited to: C. Routine care
orders to maintain or improve the resident's functional abilities .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455497
If continuation sheet
Page 2 of 2
