Inspection·July 11, 2023

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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #24)7 residents reviewed for care plans. The care plans for Residents #24 failed to address her dementia diagnosis and what services would be provided to maintain the resident's needs These failures could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings included: 1. Review of the MDS assessment dated [DATE] revealed Resident #24 was an [AGE] year-old female with BIMS score 12 who was admitted to the facility on [DATE]. The resident's diagnoses included: depression, bipolar (mood) disorder, and non-Alzheimer's dementia (mental decline). Review of Resident #24's Comprehensive Care Plan initiated 11/30/17 revealed it did not address Resident #24's dementia. Interview with REG N on 07/11/23 at 12:00 AM revealed facility staff overlooked Resident #24's MDS and missed the dementia diagnosis. REG N stated that if residents were admitted all their diagnosis should be in the care plan. REG N stated the purpose for the care plan was to put in place interventions so staff could properly manage residents' care. REG N stated that by Resident #24 having an incomplete care plan for dementia she could potentially become more confused. When asked who is responsible for ensuring care plans are complete, Reg N responded LVN A and LVN B are but are on leave. Interview with the DON on 07/11/23 at 12:25 PM revealed facility staff updated how they did care plans by doing standard care meetings. DON stated every week she reviews everything regarding the residents from admission and onwards and documents on a checklist during the standard of care meetings. [NAME] stated that staff has a checklist to use for any changes that occurred with the resident( vitals, med profile, medications). DON stated the facility must have missed the diagnosis for Resident #24 by accident. The DON stated the dementia diagnosis should have been care planned. The DON stated that if Resident #24 was not properly care planned for dementia, that could lead to a decline in care and affect her daily activities. (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: 675201 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 675201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Medical Lodge 300 S. Highway 36 Bypass Gatesville, TX 76528 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)