Health inspection·June 23, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care. The facility failed to give Resident #1 his Biofreeze Gel 4% scheduled medication during the standard time frame for 13 days and did not get his Biofreeze Gel at all on 06/19/2025. These failures placed residents at risk of pain, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 06/23/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: pain in joint, muscle wasting, and type 2 diabetes mellitus with diabetic neuropathy (nerve damage due to diabetes). Record review of Resident #1's Quarterly MDS assessment, dated 04/29/2025, reflected the resident had a BIMS score of 15, which indicated intact cognitive response. Resident #1 required partial/moderate assistance in the areas of toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS revealed that the resident had frequent pain, the resident had scheduled and PRN pain medication. Record review of Resident #1's care plan, dated 05/08/2025, reflected Resident #1 was care planned for pain: resident has complaints of chronic pain related to bilateral lower extremity amputee. The approach was monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factors. Record review of Resident #1's Biofreeze order dated 4/28/2025 revealed the Biofreeze was ordered twice a day at 8:00am and 8:00pm. Apply to bilateral hands with reminder not to touch face, sensitive skin areas, until completely dry. Record review of Resident #1's Medication Administration Record (MAR) for Biofreeze Gel 4% revealed the topical gel was scheduled twice a day at 8:00am and 8:00pm. The MAR revealed that staff gave the resident the cream at the following dates and times. Scheduled Date Page 1 of 6 676382 676382 06/23/2025 Falcon Ridge Rehabilitation 149 Klattenhoff Lane Hutto, TX 78634

F 0755 Scheduled Time Level of Harm - Minimal harm or potential for actual harm Charted Date - Time (GIVEN) 06/10/2025 Residents Affected - Some 8:00 AM 06/10/2025 - 10:50 AM 8:00 PM NOT GIVEN 06/11/2025 8:00 AM 06/11/2025 - 10:34 AM 8:00 PM 06/11/2025 - 09:28 PM 06/12/2025 8:00 AM 06/12/2025 - 12:44 PM 8:00 PM 06/12/2025 - 10:36 PM 06/13/2025 8:00 AM 06/13/2025 - 10:35 AM 8:00 PM 06/14/2025 - 12:13 AM 06/14/2025 8:00 AM NOT GIVEN 676382 Page 2 of 6 676382 06/23/2025 Falcon Ridge Rehabilitation 149 Klattenhoff Lane Hutto, TX 78634

F 0755 8:00 PM Level of Harm - Minimal harm or potential for actual harm 06/14/2025 - 10:15 PM 06/15/2025 Residents Affected - Some 8:00 AM 06/15/2025 - 10:04 AM 8:00 PM 06/16/2025 - 12:06 AM 06/16/2025 8:00 AM 06/16/2025 - 11:56 AM 8:00 PM NOT GIVEN 06/17/2025 8:00 AM 06/17/2025 - 12:21 PM 8:00 PM NOT GIVEN 06/18/2025 8:00 AM 06/18/2025 - 11:12 AM 8:00 PM 06/18/2025 - 11:24 PM 06/19/2025 8:00 AM NOT GIVEN 676382 Page 3 of 6 676382 06/23/2025 Falcon Ridge Rehabilitation 149 Klattenhoff Lane Hutto, TX 78634

F 0755 8:00 PM Level of Harm - Minimal harm or potential for actual harm NOT GIVEN 06/20/2025 Residents Affected - Some 8:00 AM 06/20/2025 - 11:48 AM 8:00 PM 06/20/2025 - 09:08 PM 06/21/2025 8:00 AM 06/21/2025 - 02:20 PM 8:00 PM 06/21/2025 - 09:03 PM 06/22/2025 8:00 AM 06/22/2025 - 09:45 AM 8:00 PM NOT GIVEN 06/23/2025 8:00 AM 0 6/23/2025 - 9:49 AM During an interview with Resident #1 on 06/23/2025 at 10:10 a.m., revealed that Resident #1 would tell the CNAs that he needed his pain medication. He said the aides would never tell the nurse that he needed the pain medication. He stated that he had not gotten his Biofreeze medication for his hands. He said he was going to the nurses' station to ask for the medication. He said he was supposed to get the Biofreeze medication twice a day. He said the staff do not always give him the Biofreeze medication. 676382 Page 4 of 6 676382 06/23/2025 Falcon Ridge Rehabilitation 149 Klattenhoff Lane Hutto, TX 78634

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation of Resident #1 on 06/23/2025 at 10:16 a.m., revealed he was asking the nurse for his Biofreeze medication. During an interview with the NP on 06/23/2025 at 10:52 a.m., revealed that staff was to give scheduled medication within an hour of the scheduled time. She stated that Resident #1's Biofreeze is a scheduled medication and not PRN. She said the negative of him not getting it depends on his pain level. She said she was not sure why staff are giving it to him late. During an interview with the DON on 06/23/2025 at 1:00 p.m., revealed that the times on the EMar for medication was the time that staff charted/gave to the resident. She also said that the time that the medicaiton was entered was the time that it was given. She said that medication was supposed to be given an hour before or an hour after. She said that she had been working with the pharmacy to change the times for giving the medication on Resident #1's hall. She said that medication pass started at 8:00 am on Resident #1's hall. She said that Resident #1 would tell the nurse that he would come to the desk to get the Biofreeze. She said that staff should have been documenting about him not taking when offered. She siad that he was not refusing the medication. She said there would be no negative outcome of not giving Resident #1 his Biofreeze. She said that she was not sure why Resident #1 had been given his medication late everyday for the past 14 days she said she was going to check into it. During an interview with LVN A on 06/23/2025 at 1:15 p.m., revealed she went to Resident #1's room at 8:05 a.m. to give him the Biofreeze gel. She said he told her to let him get up and that he was going up to the nurses' station to get his pain medications and Biofreeze. She said she took the medication back down to Resident #1's room again at 9:49 a.m. She said Resident #1 told her again he was coming. She said Resident #1 did not refuse, he said not right now. She said she did not want to put refused because Resident #1 would take the medication later. She said that if she puts refuse then Resident #1 cannot get the medication. She said by Resident #1 not taking the medication at the time she would take it to him it did put him out of the range for medication administration. She said the policy stated one hour before or one hour after. She said Resident #1 was ordered the Biofreeze twice a day at 8:00 am and 8:00 pm not when Resident #1 wanted to take the medication. She said the times in the administration record is the times that he was getting the medication. She said staff do not follow the doctor order on the Biofreeze. She said she was not sure if she had talked to the doctor or NP regarding the Biofreeze. She said that when the doctor was notified the doctor told her to just give him the Biofreeze. She said that she did not have the doctor write an order stating Resident #1 could have the Biofreeze when he wanted. She said staff was to let the doctor know if when a resident did not want their medication. When asked what could happen if he did not get his cream on time or at all and she responded that he did not go without the Biofreeze. During an interview with the ADM on 06/23/2025 at 2:29 p.m., revealed he had been trained on medication administration. He said the policy was for scheduled medications, ordered at a specific time should be given within the parameters. He said the parameters for medications was one hour before and one hour after. He said the parameters did apply to scheduled creams. He said that the negative outcome depended on the type of medication. He said some medications was not as severe as other. He did say that pain did affect the resident's quality of life. He said Resident #1 would tell the nurse he did not want the medication at the time ordered. He said he would try to get the Biofreeze order changed to as needed. Record review of the Nursing Policies and Procedures Medication Management Program revised May 05, 2023, revealed medications are administered no more than one hour before to one hour after the 676382 Page 5 of 6 676382 06/23/2025 Falcon Ridge Rehabilitation 149 Klattenhoff Lane Hutto, TX 78634

F 0755 medication pass time. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676382 Page 6 of 6