Inspection·May 14, 2025

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of Resident #2 plate in the room, interviews with staff, and record reviews, the facility failed to ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs for Resident #2 (1 of 1 Resident reviewed). The facility failed to follow the care plan and provide Resident #2 with a mechanically soft diet that he could eat. This could cause the resident to experience unplanned weight loss due to inability to eat properly. The facility failed to prepare a textured diet to the consistency required for Resident #2. The findings included: Record review of Resident #2's admission Record, dated 05/14/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #2's Medical Diagnosis EMR tab, accessed on 05/14/2025, reflected Resident #2 had diagnoses which include ; type 2 diabetes mellitus with hyperglycemia. Record review of Resident #2's care plan undated and accessed 05/14/2025, reflected the following focuses and interventions: - Focus: The resident has ADL self-care performance deficits and limitations in eating food. Activity Intolerance 05/12/2025, including: - Low Concentrated Sweets diet, Mechanical Soft texture, Regular consistency - Review of Resident #2's MDS showed a BIM score of 7. During an interview on 5/14/2025 at 12:50 PM., Resident #2 stated that he had seven teeth pulled a few days ago, and he cannot eat some of the food provided to him at the facility. Surveyor observed that Resident #2 had a whole sandwich on his plate, but said he couldn't eat it. Resident #2 said that he eats what he can on the plate. There was no visible meal ticket on the tray at the time. During an interview on 5/14/2025 at 2:15 PM., CKA said she works the evening shift and has been at the facility for eight months. CKA knew that Resident #2 was to be served mechanically soft food. CKA said that she was verbally told that Resident 2 was to be served mechanical soft. [NAME] #2 stated that the normal process is for a nurse to bring back the information form with the resident's approved food textures. (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 3 Event ID: 675468 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 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)