Health inspection·May 2, 2024

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 interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Resident #4 and Resident #5) reviewed for care plans. 1. The facility failed to ensure that Resident #4 had a care plan in place for his use of diuretic medication. 2. The facility failed to ensure that Resident #5 had a care plan in place for her use of diuretic medication. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Review of Resident #4's admission Record dated 5/2/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included end stage renal disease with dependence on renal dialysis, congestive heart failure, and benign prostatic hyperplasia (prostate gland enlargement that can cause difficulty urinating). Review of Resident #4's admission MDS assessment dated [DATE] revealed his short and long-term recall was ok and he was able to independently make consistent/reasonable decisions. He was independent or required only supervision for all ADLs. He was occasionally incontinent of bowel and bladder. He was taking a diuretic and he was receiving hemodialysis. Review of Resident #4's Order Summary Report dated 5/2/24 revealed the following: Furosemide Oral Tablet 40mg 1 tablet by mouth one time a day for edema (revision date 4/22/24) Review of Resident #4's care plan, most recent revision date 4/22/24, revealed no care plan in place for his diuretic use. Review of Resident #5's admission Record dated 5/2/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic peripheral venous insufficiency (when the veins in the legs do not allow blood to flow back up to the heart), pulmonary heart (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: 676031 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 676031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Creek Nursing and Rehabilitation 4343 Oak Grove Blvd San Angelo, TX 76904 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)