Health inspection·March 20, 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 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, which include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of six residents (Resident #36) reviewed for comprehensive care plans. The facility failed to ensure Resident #36's care plan addressed that the resident received hospice service. This deficient practice could result in a loss of quality of life due to residents receiving improper care. Findings include: Record review of Resident #36's face sheet, dated 3/19/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had diagnoses which included COPD (a lung disease which makes breathing difficult), chronic congestive heart failure (the heart is not able to pump enough blood to meet the body's needs), anxiety, pneumonia and type 2 diabetes. Record review of Resident #36's Hospice Informed Consent/Election of Hospice Benefit form, dated 12/31/2024, signed by the POA revealed Resident #36 would be receiving hospice service from [hospice agency] starting on 1/1/2025. Record review of Resident #36's physician orders, dated 1/1/2025, revealed a physician order of Admit to [hospice agency] with admitting diagnosis as COPD. Record review of Resident #36's care plan, dated 1/29/2025, revealed no care plan for hospice service. In an interview on 3/20/2025 at 1:36 PM, the ADON stated hospice service should be care planned because the care plan let staff know how to care for a resident. She stated the risk of a care plan not being up to date could result in residents not getting proper care . In an interview on 3/20/2025 at 1:42 PM, the DON stated if a resident was on hospice, it was considered a change in status. The DON stated she had to update the face sheet, make sure there was an order in place for hospice service, and update the care plan. She stated she and the ADON met every Page 1 of 4 676382 676382 03/20/2025 Falcon Ridge Rehabilitation 149 Klattenhoff Lane Hutto, TX 78634

F 0656 Friday to go over residents, to update their care plans as needed, Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Care plan policy & procedures, dated 5/5/2023, revealed the facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident .the facility will initiate person-centered care plans when the resident's clinical status or change of condition occurs. Residents Affected - Few 676382 Page 2 of 4 676382 03/20/2025 Falcon Ridge Rehabilitation 149 Klattenhoff Lane Hutto, TX 78634

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Few The facility failed to ensure food in the dry storage area was kept off the floor. This failure could affect residents by placing them at risk for accumulation of insects and/or rodents causing food-borne illness. Findings included: In an observation on 3-18-2025, at 8:45 AM, in the facility's dry food storage area, one loaf of bagged bread was observed to be on the floor. In an interview with the Dietary Manager on 3-20-2025 at 11:00 AM, it was revealed the Dietary Manager had worked at the facility for one month. The Dietary Manager said that it is all the kitchen staff's responsibility to ensure food in the dry storage area is kept off the floor to prevent cross contamination to the residents. The Dietary Manger stated his expectation was for food to be kept 6 inches off the floor and if food falls on the floor for it to be thrown away in the trash. In an interview with the Dietician on 3-20-2025 at 11:34 AM, it was revealed that the Dietary Manager was responsible to ensure food, in the dry storage area, is kept off the floor. The Dietician stated her expectation for food in the dry storage area was for food to be kept off the floor. The Dietician stated if food falls on the floor, she expected the food to be thrown away. The Dietician stated the potential risk to residents, when food was on the floor, was for cross contamination and food borne illness. In an interview with the Administrator on 3-20-2025 at 2:00 PM, it was conveyed that the facility followed a policy and procedure regarding food kept in the dry storage area of the kitchen. The Administrator said he expected food in the dry storage area to be kept off the floor to prevent rodents from getting into the food. The Administrator stated he expected food to be thrown that fell on the floor. The Administrator said the potential risk to residents, when food is not kept off the floor was that it could create pest control issues. Record review of the facility's Nutrition Policies and Procedures Policy dated 2020 and revised 6-20-2023 stated General Food Storage Guidelines . Dry Storage Guidelines - (focus shall be to keep non-refrigerated foods, disposable dishware, and napkins in a clean dry area, which is free of contaminants.) 1. Store foods at least 6 of the floor . 676382 Page 3 of 4 676382 03/20/2025 Falcon Ridge Rehabilitation 149 Klattenhoff Lane Hutto, TX 78634

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, it was revealed that 1 of 2 trash dumpsters, reviewed for proper trash containment, was not maintained in a sanitary condition to prevent the harborage of feeding pest. Residents Affected - Some The facility failed to ensure an outside trash dumpster was properly sealed with the lid closed. This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents. Findings included: During an observation on 3-18-2025 at 9:00 AM, a large trash receptacle, containing trash, was in the back parking lot with the lid open. This trash dumpster was observed to not be in use. In an interview with the Dietary Manager on 8-18-2025 at 9:10 AM, it was conveyed the entire kitchen staff were responsible for keeping the lid closed on the trash dumpster when not in use. The Dietary Manager started that he expected staff to keep the lid closed on the dumpster as there was a risk of debris blowing outside the facility around residents. In an interview with the Dietician on 3-20-2025 at 11:34 AM, it was stated that her expectation was for the garbage dumpster to have its lid closed when not in use. The Dietician said she was not sure who was responsible for ensuring the lid stays closed. The Dietician said the risk to residents for not keeping the trash dumpster lid closed was the accumulation of rodents and insects. In an interview with the Administrator on 8-20-2025 at 2:10 PM, it was revealed that the kitchen staff are responsible to ensure the outside garbage dumpster's lid stayed closed. The Administrator said the risk to residents, leaving a trash dumpster lid open, was the potential for rodents to accumulate. Record review of the facility's policy dated 2020 and revised on 6-20-2023 titled: Nutrition Policies and Procedures stated: Subject: Cleaning Trash Cans Policy: Trash cans are kept covered. They will be maintained in a clean, sanitary conditions . 676382 Page 4 of 4