F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
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 residents who were unable to carry out
activities of daily living received necessary services to maintain good personal hygiene for 1 (Residents #2)
of 4 residents reviewed for ADL's.
Residents Affected - Few
1. The facility failed to ensure Resident #2 was getting assistance with changing her brief and catheter care
as needed.
This failure had the potential to affect residents by placing them at risk for skin breakdown and a decline in
their quality of life.
Findings included:
Review of Resident #2's MDS assessment, dated 08/22/23, reflected she was a [AGE] year-old-female who
admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included
morbid obesity and chronic obstructive pulmonary disease. She was always incontinent of bladder and
bowel and had an indwelling catheter.
Review of Resident #2's Physician's Orders, dated 09/13/23 reflected a new order (following Surveyor
intervention) was written for:
Change briefs every shift even if it's not wet or has bowel movement every shift.
Additional orders included:
07-14-23 Foley Catheter Care every shift and as needed.
Review of Resident #2's September 2023 MARs/TARs reflected the nurses had documented the catheter
care was completed.
Review of Resident #2's Care Plan, dated 08/17/21, reflected:
The resident has bowel incontinence and prefers to be laying/sitting in bed when she has bowel elimination.
Facility interventions included to check resident every two hours and assist with incontinent care as
needed.
There was no care plan for Foley catheter or catheter care.
(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 10
Event ID:
455930
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
455930
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Ridge Rehabilitation and Healthcare Center
1700 N Washington
Pilot Point, TX 76258
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 0677
Level of Harm - Minimal harm
or potential for actual harm
An observation and interview on 09/13/23 at 10:55 AM revealed Resident #2 was lying in a bariatric bed.
She was awake, alert, and oriented. She had a Foley catheter with yellow-orange urine. She said she was
not receiving catheter care or brief changes and went three days, 08/18/23-08/21/23 without a brief change.
She said she was able to press her call light and ask for help, but the problem was that staff would not
assist her. She said she did not know why staff would not assist her.
Residents Affected - Few
An interview on 09/13/23 at 4:50 PM with LVN B revealed Resident #2 did not receive a brief change from
08/18/23 - 08/21/23. She said the resident was not receiving routine brief changes and to prove it, CNA D
dated and timed Resident #2's brief for 08/18/23, 2:00-10:00 PM shift. LVN B said when she and CNA D
returned to work on 08/21/23 for the 2:00 PM-10:00 PM shift; the resident still had a Foley catheter and the
resident was still wearing the same brief. LVN B said Resident #2 reported that no one provided catheter
care or a brief change for her 08/18/23-08/21/23. LVN B said she reported the incident to the DON.
An interview on 09/13/23 at 5:15 PM with CNA D revealed on 08/18/23 at 9:45 PM she changed the brief
for Resident #2. She said she put the date and time on the brief because the resident told her she was not
receiving incontinence care. She said she came in to work on 08/21/23 at 2:00 PM and the resident was
wearing the same brief. CNA D said she then changed the resident's brief. CNA D said she reported the
incident to LVN B. CNA D said the resident continued to not receive brief changes , but she did not report it
further because the DON was already aware. CNA D said there were many shifts when she came to work
that the resident was incontinent and had been left that way. She said the resident was not receiving
catheter care as ordered either. She said the staff would just peek in on her and did not know why they did
not want to go into her room.
An interview on 09/14/23 at 10:00 AM with the Administrator revealed she was aware Resident #2 did not
receive a brief change from 08/18/23-08/21/23. She said the DON told her about it and had spoken to staff
about it. The Administrator said she thought the resident had received catheter care during that time, just
not a brief change. She said the resident was supposed to receive catheter care every shift and as needed.
An interview on 09/14/23 at 11:35 AM with LVN E revealed she said she performed catheter care as
ordered for Resident #2 on 08/18/23 - 08/21/23. She said she did not change the resident's brief because it
was not soiled. She said the brief stayed clean and dry. She said she did not notice a date and time on the
brief and that catheter care was ordered every shift and residents were supposed to receive a brief change,
if it was soiled, every 2 hours. She said she did not know why the resident said she did not receive the
catheter care. She said that she was not able to make sure the CNAs changed the resident's brief because
she did not have time. She said there could be skin breakdown if a brief was not changed when soiled.
An interview on 09/14/23 at 12:05 pm with CNA F revealed he worked with Resident #2 from
08/18/23-08/21/23. He said he did not remember if he gave the resident a brief change. He said he was
supposed to change a resident's brief every two hours. He said he did not know if the nurses provided the
resident with catheter care.
An interview on 09/14/23 at 12:30 PM with LVN G revealed she was assigned to Resident #2 from
08/18/23-08/20/23 for the 10:00 PM - 6:00 AM shift. She said she documented providing catheter care but
did not actually provide it. She said the resident refused the care.
An interview on 09/14/23 at 12:35 PM with LVN H revealed she said she provided care to Resident #2
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455930
If continuation sheet
Page 2 of 10
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
455930
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Ridge Rehabilitation and Healthcare Center
1700 N Washington
Pilot Point, TX 76258
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
on 08/21/23 for the 6:00 AM-2:00 PM shift. She said she did the catheter care. She said a resident's brief
was supposed to be changed every shift. She said she did not make sure the resident's brief was clean and
dry, she usually would just check to make sure the resident was comfortable.
An interview on 09/14/23 at 12:55 PM with the DON revealed she was aware Resident #2 did not receive
brief changes from 08/18/23-08/21/23. She said she talked to 2 CNAs about it . She said the brief was
supposed to be changed every shift even if it was not soiled. The DON said the nurses said they did the
catheter care. The DON said she understood the CNA's point of view that the brief did not need to be
changed if it was not soiled. The DON said she spoke to the resident and told her that her brief would be
changed at least every shift. The DON said she did not know what the policy said about when a brief should
be changed, and that skin breakdown could occur if a brief was not changed.
Review of the Facility Policy, Catheter Care, Urinary, dated January 2023, reflected:
Equipment and Supplies
The following equipment and supplies will be necessary when performing this procedure:
1. Wash basin;
2. Soap and water;
3. Washcloth;
4. Towel;
5. Bed protector; and
6. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed).
Steps in the Procedure
1. Place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be
easily reached.
2. Wash and dry your hands thoroughly.
3. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside
stand within easy reach.
4. If the resident's physical or medical condition permits, assist the female resident into the dorsal
recumbent position .
5. Put on gloves.
6. Place bed protector under resident.
7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455930
If continuation sheet
Page 3 of 10
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
455930
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Ridge Rehabilitation and Healthcare Center
1700 N Washington
Pilot Point, TX 76258
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 0677
and towel dry.
Level of Harm - Minimal harm
or potential for actual harm
8. Pour wash water down the commode. Flush the commode.
9. Place soiled linen into designated container.
Residents Affected - Few
10. Put on clean gloves.
11. Remove gloves and discard into the designated container. Wash and dry your hands thoroughly.
12. Provide privacy. Cover the resident with a sheet, exposing only the perineal area.
13. With nondominant hand separate the labia of the female resident or retract the foreskin of the
uncircumcised male resident. Maintain the position of this hand throughout the procedure.
14. Assess the urethral meatus.
15. For a female resident: Use a washcloth with warm water and soap to cleanse the labia. Use one area of
the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each
downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. Do
not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm
water using the above technique .
17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site
to approximately four inches outward.
18. Secure catheter utilizing a leg band.
19. Check drainage tubing and bag to ensure that the catheter is draining properly.
20. Discard disposable items into designated containers. Remove gloves and discard into designated
container. Wash and dry your hands thoroughly.
21. Reposition the bed covers. Make the resident comfortable.
22. Place the call light within easy reach of the resident .
Review of the facility policy, Perineal Care, dated February 2023, reflected:
Purpose
The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections
and skin irritation, and to observe the resident's skin condition .
For a female resident:
a. Wet washcloth and apply soap or skin cleansing agent.
b. Wash perineal area, wiping from front to back.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455930
If continuation sheet
Page 4 of 10
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
455930
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Ridge Rehabilitation and Healthcare Center
1700 N Washington
Pilot Point, TX 76258
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
(1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling
catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches.
Gently rinse and dry the area.)
(2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in
same direction, using fresh water and a clean washcloth.
(3) If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the
leg to avoid traction or unnecessary movement of the catheter.
(4) Gently dry perineum.
c. Ask the resident to turn on her side with her top leg slightly bent, if able.
d. Rinse wash cloth and apply soap or skin cleansing agent.
e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the
buttocks.
f. Rinse and dry thoroughly.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455930
If continuation sheet
Page 5 of 10
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
455930
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Ridge Rehabilitation and Healthcare Center
1700 N Washington
Pilot Point, TX 76258
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure a resident who was incontinent of
bladder receives appropriate treatment and services to prevent urinary tract infections and to restore
continence to the extent possible for one (Resident #1) of three residents observed for infection control.
CNA A failed to ensure Resident #1's Foley catheter did not pull or hang from the resident during
incontinence care.
This failure could place residents at risk for infection and or trauma at the catheter site.
Findings included:
Review of Resident #1's MDS, dated [DATE], reflected he was admitted on [DATE]. He was 72 years' old.
He had a diagnosis of stroke. The resident was incontinent of urine and stool and had an indwelling
catheter .
An interview and observation on 09/13/23 at 11:55 AM with Resident #1 revealed he was lying in bed with
his blanket pulled back. He was alert and able to answer questions. He was wearing a brief and was
incontinent of a large amount of stool that was spilling from his brief. He said he was waiting for staff to
come change him. He had a Foley catheter hanging off the bed frame of his bed. The Surveyor notified the
staff that the resident was incontinent of stool. At 12:00 PM, CNA A entered Resident #1's room. CNA A
drained cloudy, yellow urine from the Foley catheter into a urinal and dumped it into the toilet. CNA A
unfastened the resident's brief and there was green stool all over it. CNA A used wipes to cleanse the
resident's peri-area and catheter tubing. CNA A removed the Foley catheter bag from the bed frame and
placed the Foley catheter bag on the floor. At 12:15 PM, CNA C entered the resident's room. CNA C
performed hand hygiene and put on gloves. CNA A was still wearing her same gloves. The resident was
turned onto his right side. The Foley catheter was not secured to his leg and was hanging from him over the
side of the bed. CNA A and CNA C cleaned the resident's stool off his body. CNA C removed her gloves
and put on new gloves. CNA A was still wearing the same gloves. The resident was rolled to his left side
and the Foley catheter continued to hang from the resident and off the side of the bed. CNA A continued to
clean the resident. The Foley catheter was cleaned and was in the penis. The penis meatus (area of the
penis next to the urethra) was torn all the way down the penis shaft (old injury per ADON.) CNA A
continued to clean the resident. The Surveyor asked the WCN, who had entered the room, if it was okay for
the Foley bag to be hanging from the resident . The WCN said no and instructed CNA A to place the bag on
the bed frame. CNA A moved to get a clean brief. CNA A put on the resident's clean brief.
An interview on 09/13/23 at 1:20 PM with the ADON revealed during incontinence care, the Foley bag
should stay at the end of the bed at bladder level so that it did not get pulled or kinked.
An interview on 09/14/23 at 1:50 PM with CNA A and the ADON revealed CNA A was supposed to empty
the Foley catheter bag and put it on the bed, so it did not stretch and hurt the resident. CNA A said that
during care for Resident #1 she forgot to. CNA A and the ADON said they did not know why Resident #1
did not have a catheter leg strap on.
Review of the facility's policy Catheter Care, Urinary revised January 2023, reflected,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455930
If continuation sheet
Page 6 of 10
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
455930
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Ridge Rehabilitation and Healthcare Center
1700 N Washington
Pilot Point, TX 76258
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 0690
. Maintaining Unobstructed Urine Flow
Level of Harm - Minimal harm
or potential for actual harm
1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter
and tubing free of kinks.
Residents Affected - Few
2. Unless specifically ordered, do not apply a clamp to the catheter.
3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the
urine in the tubing and drainage bag from flowing back into the urinary bladder .
Be sure the catheter tubing and drainage bag are kept off the floor .
Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion
site. (Note: Catheter tubing should be strapped to the resident's inner thigh.)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455930
If continuation sheet
Page 7 of 10
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
455930
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Ridge Rehabilitation and Healthcare Center
1700 N Washington
Pilot Point, TX 76258
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 0880
Provide and implement an infection prevention and control program.
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 maintain an Infection Prevention and Control
Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the
development and transmission of communicable diseases and infections for one (Resident #1) of three
residents observed for infection control.
Residents Affected - Few
CNA A failed to perform hand hygiene and glove changes while providing incontinence care to Resident #1.
This failure could place residents at risk for spread of infection through cross-contamination.
Findings included:
Review of Resident #1's MDS, dated [DATE], reflected he was admitted on [DATE]. He was 72 years' old.
He had a diagnosis of stroke.
An interview and observation on 09/13/23 at 11:55 AM with Resident #1 revealed he was lying in bed with
his blanket pulled back. He was alert and able to answer questions. He was wearing a brief and was
incontinent of a large amount of stool that was spilling from his brief. He said he was waiting for staff to
come change him. His right hand was contracted and was lying in stool. He had a Foley catheter hanging
off the bed frame of his bed. There was a stool covered napkin lying on top of his bedside table. The
Surveyor notified the staff that the resident was incontinent of stool. At 12:00 PM, CNA A entered Resident
#1's room. CNA A already had gloves on , picked up the stool soiled napkin and threw it in the trashcan.
CNA A pulled the resident's grey blanket back, which had stool on it, picked it up, rolled it up and laid it on
the bedside table. CNA A left the room and returned with a plastic bag and put the grey blanket in the
plastic bag. CNA A drained the cloudy, yellow urine from the Foley catheter into a urinal and dumped it into
the toilet. CNA A was still wearing the same gloves and did not perform hand hygiene. CNA A got a clean
sweater from the closet and prepared supplies. CNA A put a liner in the trashcan and filled a basin with
water. CNA A unfastened the resident's brief and there was green stool all over it. CNA A removed the
resident's right hand from the stool. The resident had stool on his fingers. CNA A used wipes to cleanse the
resident's peri-area and catheter tubing. CNA cleaned off stool from the right leg with wipes and the
resident's right hand. CNA A removed the Foley catheter from the bed frame and placed the Foley catheter
bag on the floor. At 12:15 PM, CNA C entered the resident's room. CNA C performed hand hygiene and put
on gloves. CNA A was still wearing her same gloves. The resident was turned onto his right side. CNA A
and CNA C cleaned the resident's stool off his body. CNA C removed her gloves and put on new gloves.
CNA A was still wearing the same gloves. The resident was rolled to his left side. CNA A continued to clean
the resident. The Foley catheter was cleaned and was in the penis. The penis meatus (area next to the
urethra) was torn all the way down the penis shaft (old injury.) CNA A continued to clean the resident. CNA
A still had not changed gloves or performed hand hygiene. The WCN entered the resident's room and
started to put her wound care supplies on the bedside table that had the napkin and blanket with stool on it.
The Surveyor intervened and told the WCN the table was soiled. The WCN cleansed the table. CNA A
moved to get a clean brief. The Surveyor intervened and asked if CNA A was going to change gloves or
perform hand hygiene. CNA A said that she already did, but the Surveyor never left the room and observed
that she had not. CNA A removed her gloves and performed hand hygiene. CNA A put on new gloves. CNA
A said it was important to perform hand hygiene and change gloves so that she did not get stool
everywhere. CNA A put on the resident's clean brief.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455930
If continuation sheet
Page 8 of 10
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
455930
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Ridge Rehabilitation and Healthcare Center
1700 N Washington
Pilot Point, TX 76258
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 0880
An interview on 09/13/23 at 1:20 PM with the ADON revealed staff was supposed to perform hand hygiene
between each glove change.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility's policy Infection Prevention and Control Program revised January 2023, reflected,
Residents Affected - Few
Policy Statement
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.
Review of the facility's policy Handwashing-Hand Hygiene Policy and Procedures revised October 2020
reflected:
Policy Statement
This facility considers hand hygiene the primary means to prevent the spread of infections .
6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:
a. When hands are visibly soiled; and .
7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or
non-antimicrobial) and water for the following situations:
a. Before and after coming on duty;
b. Before and after direct contact with residents;
c. Before preparing or handling medications;
d. Before performing any non-surgical invasive procedures;
e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites);
f. Before donning sterile gloves;
g. Before handling clean or soiled dressings, gauze pads, etc.;
h. Before moving from a contaminated body site to a clean body site during resident care;
i. After contact with a resident's intact skin;
j. After contact with blood or bodily fluids;
k. After handling used dressings, contaminated equipment, etc.;
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455930
If continuation sheet
Page 9 of 10
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
455930
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Ridge Rehabilitation and Healthcare Center
1700 N Washington
Pilot Point, TX 76258
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 0880
l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident;
Level of Harm - Minimal harm
or potential for actual harm
m. After removing gloves;
n. Before and after entering isolation precaution settings;
Residents Affected - Few
o. Before and after eating or handling food;
p. Before and after assisting a resident with meals; and
q. After personal use of the toilet or conducting your personal hygiene.
8. Hand hygiene is the final step after removing and disposing of personal protective equipment.
9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with
routine
10. hand hygiene is recognized as the best practice for preventing healthcare-associated infections
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455930
If continuation sheet
Page 10 of 10