Health inspection·April 30, 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 interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #1) of four residents reviewed for Care Plans. The facility failed to ensure Resident #1's history of falls were care planned. This failure could place the resident at risk of not receiving the necessary care and services needed. Findings included: Record review of Resident #1's Face Sheet, dated 04/30/25, reflected she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle weakness, lack of coordination, and dizziness. Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/15/25, reflected she had a BIMS score of 10 (moderate impairment). Resident required extensive assisted with ADL care. Record review of the facility's incident report and Resident #1's progress notes on 04/30/25, reflected the resident had an unwitnessed fall on 03/14/25, which resulted in no injuries. Record review of Resident #1's Quarterly Care Plan, dated 11/19/24, did not reflect a care plan for the resident's history of falls. In an interview on 04/30/25 at 11:00 AM, the ADON stated Resident #1 had a fall in March 2025 and she was considered at high risk for falls. She stated the resident should have been care planned for falls, but it was not done. She stated the DON at the time should have care planned the fall risk. She stated the ADON, the MDS nurse, and the DON were responsible for ensuring the resident was care planned as a fall risk. She stated the risk of not care planning the fall risk was it could impact the resident not having the proper precautions in place. In an interview on 04/30/25 at 11:15 AM, the MDS nurse stated Resident #1 had a fall on 03/14/25. She was considered a fall risk and all the residents at the facility were considered a fall risk. She Page 1 of 2 455930 455930 04/30/2025 Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258

F 0656 Level of Harm - Minimal harm or potential for actual harm stated based on the neurological report completed on 03/14/25, the resident should have been care planned for falls, but she was not. She stated the ADON, the DON, and herself were responsible for ensuring the residents care plans were updated and this resident's care plan should have been updated by the DON at the time. She stated the DON was no longer at the facility. She stated the risk of not care planning her fall could result in missed care to the resident. Residents Affected - Few Record review of the facility's policy, Care Plans and CAAs (Care Area Assessments) (05/06/16) revealed It is the intent of Advanced Health Care Solutions to meet and abide by all State and Federal regulations that pertain to resident care plans and subsequent Care Area Assessments (CAAs) completion. The purpose of this guide is to ensure that an interdisciplinary (IDT) approach is utilized in addressing the Care Area Triggers (CATs) that were generated by the completion of the Minimum Data Set (MDS) in order to effectively address the Care Area Assessments (CAAs) and ultimately achieve the completion of an effective comprehensive plan of care for each resident. 455930 Page 2 of 2