Health inspection·November 15, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 7 (Resident #1) residents reviewed for care plan revisions. The facility failed to revise Resident #1's care plan to reflect interventions for falls related to unsteadiness during transfers and only able to stabilize with staff assist initiated on 10/28/20 and revised on 07/26/22. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: Record review of Resident #1's admission record dated 11/14/25 documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: type 2 diabetes (pancreas doesn't make enough insulin, essential hypertension (high blood pressure), muscle weakness (loss of muscle strength), and lack of coordination (damage or brain coordination system). Record review of Resident #1's Quarterly MDS assessment, dated 09/22/25, revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. Record review of Resident #1's care plan, dated 10/27/25, revealed Resident #1 was care planned on 10/28/20 and revised on 07/26/22 for falls related to unsteadiness during transfers and only able to stabilize with staff assist. During an interview on 11/15/25 at 1:28 p.m., the DON stated it was expected for the care plans to be accurate and updated. The DON stated that the MDS Coordinator was responsible for updating the care plans. The DON stated that care plans were detailed communication of the residents so staff would know how to assist a resident. The DON stated when the interventions were not in place staff would know how to care for the residents . During an interview on 11/15/25 at 1:30 p.m., the MDS Coordinator stated he was responsible for updating the care plans. The MDS Coordinator stated he was expected for him to update the care plan with the interventions so staff would know how to assist the residents. The MDS Coordinator did not have a reason why Resident #1 fall intervention was not updated in the care plan and he could not recall. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 2001 revised December 2016, indicated, 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. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 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: 675903 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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)