Health inspection·November 24, 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 observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, 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 1 of 6 (Resident #1) reviewed for care plans.Facility staff failed to follow the fall interventions in Resident #1's care plan that included keeping Resident #1's bed in the lowest position. Resident #1's was observed lying in bed and the bed was not at the lowest position on 11/06/2025. This deficient practice could place residents with the potential for falls at risk for injury to themselves or others. The findings included:Record review of Resident #1's undated face sheet revealed Resident #1 was an [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included Dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #1's MDS assessment, dated 10/04/2025, revealed a BIMS score of 3, indicating severe cognitive impairment. Section GG - Functional Abilities revealed Resident #1 had impairment on both sides of Resident #1's upper and lower extremities and was dependent on staff for bed mobility and transfers. Record review of Resident #1 physician's order summary report, dated 11/07/2025, revealed an order, low bed every shift for fall precautions, dated 11/29/2022 and fall precautions at all times every shift, dated 11/03/2025. Record review of Resident #1 undated comprehensive care plan revealed a care plan, [Resident #1] had an actual fall with subdural hematoma (bleeding near the brain), dated 10/31/2025 and revised 11/03/2025. An intervention revealed, low bed, dated 10/23/2025. Resident #1 had a care plan that revealed, [Resident #1] is a high risk for falls related to senile degeneration of brain, poor insight to deficits, and poor safety awareness. [Resident #1] is in a low bed and has a fall mat in place, dated 02/10/2022 and revised 10/23/2025. During an observation of Resident #1 and an interview, 11/06/2025 at 9:14 a.m., Resident #1 was observed lying in her bed with the bed in a standard knee height position and not lowered to the lowest level. Resident #1 had a fall mat beside the bed. A sign was observed on Resident #1's bulletin board at the foot of Resident #1's bed that revealed, low bed and fall mat. A bed remote was observed hanging on the outside of Resident #1's quarter rail and Resident #1 stated she did not use the remote to change the level of Resident #1's bed. During an interview with RN B, 11/06/2025 at 9:20 a.m., RN B observed Resident #1's bed and stated Resident #1 was supposed to have her bed lowered to the lowest position and stated Resident #1's bed was not in the lowest position. RN B stated she was the nurse assigned to Resident #1 and RN B stated all staff were responsible for ensuring Resident #1's bed was in the lowest position. RN B stated she had received training on keeping resident beds in the position for residents at risk for falls as a preventive measure to prevent falls. RN B stated Resident #1 was a fall risk and stated if Resident #1's bed was not in the low position, if she fell, the injuries could be worse because she is falling Page 1 of 2 675502 675502 11/24/2025 Pleasanton North Nursing and Rehabilitation 404 Goodwin St Pleasanton, TX 78064

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from a higher position than if the bed was in a low position. During an interview with the DON, 11/07/2025 at 11:00 a.m., the DON stated staff had received training on fall prevention to include keeping resident beds in a low position if the resident was at risk for falls. The DON stated all staff were responsible for keeping beds in the low position and stated staff could identify residents at risk for falls by the sign posted in a resident room that read, low bed. The DON stated it was important for beds to be in the low position for a resident at risk for falls because, they could fall and be injured. Record review of a facility policy titled, Comprehensive Care Plans (Copyright 2025), revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. 675502 Page 2 of 2