Health inspection·June 12, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 2 residents reviewed for quality of care. Residents Affected - Few The facility failed to ensure the nurses initialed and dated wound dressings when wound care was performed on Resident #1 This failure could result in residents with wounds not having their treatments performed as ordered, wounds becoming infected, and decreased wound healing. Findings include. Record review of face sheet dated 6/11/24 indicated Resident #1 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including Hemiplegia (weakness caused by brain or spinal cord problems) and Hemiparesis (weakness on one side) following Cerebral Infarction (blood in the brain) affecting left non-dominant side, Cerebellar Stroke Syndrome, unsteadiness on feet, muscle weakness, reduced mobility, depression, Hyperlipidemia (high levels of fat) and disorder of the Autonomic Nervous system. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS of 1 which indicates severe cognitive impairment. Record review of the physician orders dated 6/10/24 indicated Resident #1, left thigh had an order to cleanse, pat dry, apply Xeroform (non-adherent, occlusive wound dressing) and super absorbent dressing every Tuesday, Thursday, and Saturday until healed. Record review of the TAR dated 6/1/24 through 6/11/24 indicated Resident #1's wound care treatment was being performed on Resident #1's left thigh by the facility. During an observation on 6/11/24 at 2:15pm, Resident #1 was sitting in his wheelchair in the dining room listening to music being played. Resident #1 was wearing shorts and the dressing to his thigh was visible. The dressing was clean and did not look old. The dressing did not have a date or initials. Interview on 6/11/24 at 2:45pm RN B stated she performed wound care on Resident #1 on 6/11/24 at 8:00 AM. RN stated she does wound care Tuesday, Thursday, and Saturday. Surveyor and RN looked at Resident #1's dressing, and the dressing was not dated or initialed. RN stated she did not have a marker (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: 675687 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 675687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Hill Inc 245 State Hwy #153 West Coleman, TX 76834 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)