Inspection·November 1, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 11 residents (Resident #7) reviewed for accuracy of clinical records. The facility did not ensure the code procedure for Resident #7 was accurately timed in nurse's note. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of physician orders dated October 2023 indicated Resident #7 was an [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired), and hypertension (a condition in which the force of the blood against the artery walls is too high). His code status was 'full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Record review of a care plan last revised 10/17/23 indicated Resident #7's code status was full code. Record review of a significant change MDS assessment dated [DATE] indicated Resident #7 had been admitted to hospice care. Record review of nurse's note dated 10/24/23 at 02:50 a.m. and signed by LVN A, indicated CNA reported Resident #7 had fallen and was found lying on the floor on his back at the foot of his bed. LVN A and 2 CNAs assisted resident back into bed and LVN A noted that resident was pale and lethargic (the state of feeling drowsy, unusually tired, or not alert). Once resident was back in bed LVN A noted he was having long periods of apnea (when you stop breathing or have almost no airflow). LVN A detected no blood pressure, pulse, or oxygenation reading at 03:05 a.m. Compressions started at 03:10 a.m. and continued until EMS arrival at facility at 03:50 a.m. During an interview on 10/31/23 at 02:32 p.m. LVN A said the times recorded in the nurse's note on 10/24/23 for Resident #7 were probably not accurate because she never noted the time of events except for the initial time of 02:50 a.m. when she entered the room and found Resident #7 in the floor. (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: 676000 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 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 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)