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 five residents reviewed
for care plans.
The facility failed to ensure Resident #1's care plan was updated to reflect a left heel wound on 06/01/2025.
These failures could place the residents at risk of not receiving the necessary care and services needed.
Findings included:
Record review of Resident #1's Face Sheet, dated 06/18/2025, reflected an [AGE] year-old male who
initially admitted to the facility 04/29/2025 and re-admitted on [DATE]. Resident #1 had diagnoses which
included chronic kidney disease stage 3 (kidneys do not function properly), heart failure (heart does not
pump effectively), and pneumonia (infection in lung). Resident #1 was discharged home on [DATE].
Record review of Resident #1's Quarterly MDS (tool used to assess health needs and functional
capabilities) Assessment, dated 05/17/2025, reflected the resident had severe impairment in cognition with
a BIMS (tool used to assess cognitive function) score of 06.
Record review of Resident #1's Physician Order, dated 06/01/2025, reflected to apply xeroform
(non-adherent wound dressing that promotes healing) and a bordered gauze dressing to the resident's left
heel.
Record review of Resident #1's Comprehensive Care Plan, dated 05/07/2025, did not reflect a left heel
wound.
During an interview on 06/20/2025 at 3:20 PM, the Administrator stated it was important to update care
plans so everyone knew what care to provide the residents. He stated if they were not updated, the resident
might not receive the appropriate care.
During an interview on 06/20/25 at 3:59 PM, the Wound Care Nurse stated she was responsible for
(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:
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
06/20/2025
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
adding or updating any skin related resident care plan. She stated it was important to include all the
resident's needs in the care plan to monitor progress and follow through with meeting the needs.
During an interview on 6/20/2025 at 4:15 PM, the MDS Coordinator stated it was important to update care
plans so staff knew how to take care of the residents. She stated the nurses, ADON, DON, and MDS
Coordinator added and updated residents' care plans. She stated the wound care nurse added or updated
a care plan for any skin issues. She stated it was important to care plan any skin issue because of the risk
for infection.
During an interview on 06/20/2025 at 4:50 PM, the DON stated it was important for each resident to have a
personalized plan of care. She stated Resident #1's wound should have been included in his care plan. She
stated resident care would not be consistent if the care plan was not personalized and updated to reflect
the resident's needs.
Record review of the facility's policy, Care Plan, Comprehensive Person-Centered, reviewed 06/02/2025,
reflected 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 . 13. Assessments of residents are ongoing and care plans are revised as information about the
residents and the residents' conditions change.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455930
If continuation sheet
Page 2 of 2
