Health inspection·December 17, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 5 residents (Residents #1) reviewed for resident rights in that: Residents Affected - Few The facility failed to ensure Residents #1's call light was within reach on 12/13/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #1's admission record dated 12/17/24 documented a [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included: quadriplegia (serve medical condition characterized by the partial or total loss of function in all four limbs and the torso), lack of coordination (not being able to move your body smoothly and precisely, often resulting in clumsiness, stumbling, or jerky movement), essential primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), cognitive communication deficit (having trouble communicating effectively due to problems with thinking skills like memory, attention, or reasoning), and polyneuropathy (a condition that occurs when multiple peripheral nerves in the body malfunction at the same time). Record review of Resident #1's Quarterly MDS assessment, dated 10/21/24, revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. The MDS also revealed Resident #1 was dependent in the areas of eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on /taking off footwear and personal hygiene. Record review of Resident #1's care plan, dated 12/20/24, revealed Resident #1 was care planned for falls related to weakness with bilateral knee contractures and decreased torso control and potential side effects to medications and had an intervention of: Keep call light within reach. Observation on 12/13/24 at 11:35 a.m., revealed Resident #1's call light was behind his bed on the floor and out of his reach. During an interview on 12/13/24 at 11:35 a.m., Resident #1 stated his call light is never in reach . Resident #1 stated staff leave his door open so he can yell for assistance. During an interview on 12/17/24 at 10:45 a.m., CNA A stated CNAs should make rounds at least every Page 1 of 8 455670 455670 12/17/2024 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few two hours or as needed. CNA A stated that CNAs should be looking to see if a resident needs assistance, ensuring call lights were within reach, and making sure all residents were comfortable. CNA A stated if a resident's call light was not within reach, then the resident could fall attempting to reach it or the resident would not receive assistance. During an interview on 12/17/24 at 2:10 p.m., the DON stated the purpose of a call light is for resident to alert staff they have needs. The DON stated that all staff that enter the residents' rooms are responsible for ensuring the residents call light is within reach. The DON stated that if a resident's call light was not within reach, then the residents' needs may not be met. An interview on 12/17/24 at 2:45 p.m., the ADM stated the purpose of call light is for the residents to alert staff they need assistance. The ADM stated its everyone's responsibility to ensure call lights are always within reach. The ADM stated that if a call light was not within reach, then a resident desired need would not be met. The ADM stated that he expects for call lights to be always within reach and answered timely. Review of the facility's Routine Resident Checks & Call Lights policy, revised July 2013, reflected, Policy Statement: Staff shall make routine resident checks to help maintain resident safety and well-being. Policy Interpretation and Implementation 1. To ensure the safety and well-being of our residents, nursing staff shall make routine resident check on each unit at least every two hours. 6. Call lights should be within arms reach while the resident is present. 455670 Page 2 of 8 455670 12/17/2024 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 3 residents (Resident #3) reviewed for privacy in that: Residents Affected - Few The facility failed to ensure CNA C provided respect and dignity by drawing the privacy curtain during peri care for Resident #3. The findings include: Record review of Resident #3's face sheet dated 12/13/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were, Pulmonary disease (Lung disease), Major depressive disorder, Shortness of breath, Muscle wasting and atrophy, Need for assistance with personal care, Cognitive communication deficit, Limitation of activities due to disability and Abnormalities of gait and mobility. Record review on 12/13/24 of Resident #3's quarterly MDS assessment, dated 09/20/24 revealed a BIMS of 03 indicating severe cognitive impairment. Record review on 12/13/24 of Resident #3's care plan dated 01/14/24 reflected resident had ADL self-care performance deficit r/t Dementia, Impaired balance, Impaired mobility, and weakness. She required one staff to assist extensively with personal hygiene and oral care. During an observation on 12/13/24 at 12:10pm CNA C provided peri care to Resident#3 in her room while her FM was present. Investigator during his visit to Resident #3 knocked at the door and heard CNA C calling out Resident Care. Investigator stated he was an RN and asking permission to enter the room so that he could observe the peri care. When he opened the door CNA C was at the final stage of peri care and the care was fully visible as Resident #3's privacy curtain was not drawn. As the CNA C had not closed the privacy curtain, Resident #3 and the peri care would have been fully visible to anyone who entered the room or to anyone in the hallway when the door was opened at that time. During further observation it was revealed Resident #3 was sharing the room with another resident and that resident was not in the room at that time. The FM stated the other resident went out for having lunch and would return any time after having the lunch. During an interview on 12/13/24 at 12:55pm CNA C stated she started working at the facility 5 days ago however had experience as CNA for many years. She stated she should have closed the privacy curtain of Resident #1. By not closing the curtain, the privacy and dignity of Resident #1 were compromised as anyone opened the door to the room could see the peri care and naked body of Resident #3. During an interview on 12/13/24 at 5:30pm the DON stated it was mandatory to respect and maintain privacy and dignity of residents during nursing care that includes peri care by closing the door and windows and drawing privacy curtains. She stated the privacy curtain of Resident #3 should have been closed completely by CNA C before commencing the peri care. She said the trainings were ongoing process and resident rights was one of them. DON stated the facility ensured all the new hires gone through skill checks. Every nursing staff also had to complete an annual evaluation to ensure their nursing skills and knowledge including competency in respecting resident's rights. During the review of facility's undated policy Privacy, reflected: 455670 Page 3 of 8 455670 12/17/2024 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0583 Level of Harm - Minimal harm or potential for actual harm Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality . Staff shall promote, maintain, and protect resident privacy during assistance with personal care and during treatment procedures. Residents Affected - Few 455670 Page 4 of 8 455670 12/17/2024 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

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 observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 5 residents (Residents #1) reviewed for resident rights in that: The facility failed to ensure Residents #1's care plan reflected his current food diet. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #1 's admission record dated 12/17/24 documented a [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included: quadriplegia (serve medical condition characterized by the partial or total loss of function in all four limbs and the torso), lack of coordination (not being able to move your body smoothly and precisely, often resulting in clumsiness, stumbling, or jerky movement), essential primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), cognitive communication deficit (having trouble communicating effectively due to problems with thinking skills like memory, attention, or reasoning), and polyneuropathy (a condition that occurs when multiple peripheral nerves in the body malfunction at the same time). Record review of Resident #1's Quarterly MDS assessment, dated 10/21/24, revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. The MDS also revealed Resident #1 was dependent in the areas of eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on /taking off footwear and personal hygiene. Record review of Resident #1's physician orders, dated 12/17/24, Resident #1 has an order for regular texture, thin liquids consistency for diet regular solids/large protein portion with meal with an order date of 07/24/24. Record review of Resident #1's care plan, dated 12/17/24, revealed Resident #1 was care planned for mechanical soft/ground meat texture with thin liquids. During an interview on 12/17/24 at 11:35 a.m., Resident #1 stated he ate regular texture food. Resident #1 stated that his diet was changed during the summer months but could not recall an actual date. During an interview on 12/17/24 at 10:45 a.m., MDS coordinator stated a care plan was to help staff identify needs to assist the residents. The MDS coordinator stated that Resident #1's current diet was Regular texture, Thin Liquids consistency. The MDS coordinator stated the potential negative outcome could been Resident #1 would have received the wrong texture diet. The MDS Coordinator stated that moving forward his expectations were that all resident's care plans would reflect the most updated and accurate information. During an interview on 12/17/24 at 2:10 p.m., the DON stated a care plan was formulated to reflect 455670 Page 5 of 8 455670 12/17/2024 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the specific needs of every resident. The DON stated Resident #1 could have received the wrong diet texture due to his care plan not reflecting his most up to date diet. The DON stated moving forward she expected for any changes regarding residents to be discussed at the morning meeting and the care plan be updated immediately. An interview on 12/17/24 at 2:45 p.m., the ADM stated a care plan should show an accurate picture for staff to follow to provide care for the resident. The ADM stated Resident #1 could have received the wrong textured food due to his care plan being inaccurate. The ADM stated it was the MDS coordinators responsibility for ensuring that the information on a resident care plan is up to date and accurate. The ADM stated his expectation were that all resident care plans reflected the most accurate and up to date information to provide the highest quality of care. Review of the facility's Care Plans, Comprehensive Person Centered policy, revised December 2016, reflected, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 3. The IDT includes: a. The attending physician; b. A registered nurse who has responsibility for the resident; c. A nurse aide who has responsibility for the resident; d. A member of the food and nutrition services staff; e. The resident and the resident's legal representative (to the extent practicable); and f. Other appropriate staff or professional as determined by the resident's needs or as requested by the resident. 13. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' condition change. 455670 Page 6 of 8 455670 12/17/2024 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 4 residents (Residents #2) reviewed for quality of care in that: Residents Affected - Few The facility failed to ensure Resident #2's oxygen mask and tubing, that were observed on 12/13/24 at 3:30pm, were not bagged for sanitation when not in use. This failure could affect residents who received oxygen therapy, by place them at risk for respiratory infections. The findings included: Record review of Resident #2's face sheet on 12/13/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were Hypertension, Type 2 diabetes, , Seasonal Allergy , Atrial fibrillation (irregular and rapid heartbeat) , Major depressive disorder and COPD. Record review on 12/13/24 of Resident #2's quarterly MDS assessment, dated 10/83/24 revealed a BIMS of 11 indicating her cognition was moderately impaired. Record review on 12/13/24 of Resident #2's care plan dated 11/03/24 indicated that she had COPD and relevant intervention was providing O2 via nasal prongs at 4.5L continuously and might titrate up to 10L/m PRN for comfort. Observation and interview on 12/13/24 at 3:30pm of Resident #2 revealed an oxygen mask sitting on the side table exposed to the environment as they were not stored in the protective bag provided. CNA B who witnessed the oxygen masks stated they were supposed to be stored in a protective bag whenever not in use. She then put it in the protective bag and stated she did not know who kept it unprotected like that. She stated protecting the mask from exposed to the environment was necessary to avoid infections especially respiratory infections. During an interview on 12/13/24 at 5:30pm the DON stated all staff supposed to be compliant with the facility policy for using oxygen cannula and nebulizers . She stated the oxygen masks were to be cleaned and safely stored in the protective bags provided . She stated due to this deficiency there was a potential for respiratory infectious diseases. Record review of the facility's policies revealed there was no policy stating safe storage of oxygen cannulas and facemasks in protective bags when not in use. Record review of facilities undated policy Infection prevention and control program reflected : An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. 455670 Page 7 of 8 455670 12/17/2024 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0695 The infection prevention and control program is developed to address the facility-specific infection control needs and requirements . Th program is reviewed annually and updated as necessary. Level of Harm - Minimal harm or potential for actual harm 2. Residents Affected - Few The program is based on accepted national infection prevention and control standards. 455670 Page 8 of 8