Health inspection·October 23, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had gotten tangled in the left wheel of his motorized scooter. Resident #1 stated he had just returned from an orthopedic appointment, and the doctor told him he no longer needed to wear a left arm sling. He stated he had injured his left shoulder when he slid out of his motorized scooter in the morning of 10/19/25. An observation on 10/23/25 at 3:19 PM of Resident #1 revealed he was clean and well-groomed and was seated in his motorized scooter with his blue mechanical lift vest in the seat underneath him. The straps of the vest were tucked in. An interview on 10/23/25 at 3:49 PM with Resident #1's RP revealed the facility had left a message for her on 10/19/25 around 8:30 AM. She stated they informed her Resident #1 had gone outside after his breakfast and had fallen from his scooter. She further stated if you talk with Resident #1, he will tell you that a strap had gotten caught in the wheel of his power scooter wheel, and that was what made it tip over and he had slid out of it an onto the ground. The RP stated she had not been aware of Resident #1 being transferred in the mechanical lift in the morning of 10/19/25 by one staff member. Review of a progress note dated 10/19/25 at 9:15 AM reflected LVN A was informed Resident #1 had fallen outside the building at approximately 8:15 AM. Upon arrival to the scene, LVN A observed Resident #1 lying face down on the ground with his scooter next to him with his right arm positioned next to his right side and his left arm was pinned across his chest. A small amount of blood was noted on the right hand. Resident #1 sustained skin tears on tip of his right hand and facial area. He was alert and oriented times 4. EMS was called; advised not to move resident until EMS arrival due to possible fracture. The ADM, the DON, and the ADON were notified via text and phone calls. The RP was notified and LVN A spoke to the RP. Resident #1 was sent to the hospital on [DATE] at approximately 9:00 AM. Review of a progress note dated 10/19/25 at 12:49 PM reflected Resident #1 returned from the hospital at 12:30 PM via EMS transport. His diagnosis was a left shoulder fracture, and pain medication was Hydrocodone 5/325mg 1 tablet by mouth every 4 hours as needed for pain. The ADM, the DON, and the RP were notified of his return to the facility. An interview on 10/23/25 at 4:37 PM with ADON A who stated she had done one-on-one training with all staff members on mechanical lift transfers. ADON A further stated monitoring included going in behind the staff and watching at least one mechanical lift transfer per day. She stated that sometimes therapy can assist with training. ADON A stated CNA A had been involved in assisting Resident #1 up on 10/19/25. She stated CNA A had been a good worker, was very respectful, and they had just conducted training with him a couple weeks ago. Review of a Wheelchair Safety Checklist dated 10/20/25 reflected the wheelchair was in good working condition and was safe to operate. Review of Safety Skills Assessment for Power Wheelchair/Scooter dated 10/21/25 reflected the power scooter had no seatbelt, Resident #1 was able to turn the device on/off independently, occasionally cuts corners too close, and going onto the narrow sidewalk may be questionable. In summary, Resident #1 was safe to use the power scooter. An interview on 10/23/25 at 5:40 PM the DON stated she had come in on Sunday, 10/19/25, after being notified of the incident of Resident #1 sliding out of his motorized scooter outside. The DON stated Resident #1 frequently strolled around outside in his motorized scooter. The DON further stated CNA A had suddenly not shown up for his scheduled shifts and to date had not answered the facility's phone calls. The DON stated CNA A's last shift worked was on Sunday, 10/19/25 on the 6am - 2pm shift. He further stated CNA A had been a no-call/no-show on Monday 10/20/25, and today 10/23/25.The DON stated she and the ADON's were responsible for ensuring and monitoring staff were conducting mechanical lift transfers with two person assist, and when staff were not transferring residents with two person assist in the mechanical lift it puts the residents at risk for falls and injuries. An interview on 10/23/25 at 5:55 PM the ADM stated Resident #1 had a history of making his own decisions, and Resident #1 knew his rights . He stated Resident #1 had a BIMS score of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676382 If continuation sheet Page 2 of 3 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 676382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falcon Ridge Rehabilitation 149 Klattenhoff Lane Hutto, TX 78634 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 15. The ADM further stated Resident #1 had been re-assessed for motorized scooter safety on 10/20/25 by OT and Speech Therapy after the incident, and it was determined Resident #1 was safe to continue to use the motorized scooter for mobility. The ADM further stated Resident #1 was given a driving exam in the therapy room and outside the facility. The ADM stated Resident #1 frequently strolled around outside in his motorized scooter. The ADM further stated CNA A had suddenly not been showing up for his scheduled shifts and was not answering their phone calls. The ADM stated CNA A's last shift worked was on Sunday, 10/19/25 on the 6am - 2pm shift. He further stated CNA A had been a no-call/no-show on Monday 10/20/25, and today 10/23/25. The ADM stated the DON/nursing was responsible for ensuring and monitoring staff were conducting mechanical lift transfers with two person assist, and when staff were not transferring residents with two person assist in the mechanical lift it puts the residents at risk for a fall and injury. Review of an in-service dated 10/04/2025 reflected CNA A had signed the in-service and received training titled, All mechanical lifts must be performed with two staff members present at all times. Review of an in-service for the policy & procedures and competency check-off dated 10/07/2025 for use of mechanical lifts reflected CNA A had passed the competency check off. The in-service additionally reflected, 1. Identifies patient/resident and introduces self & co-worker to patient/resident (and family, if appropriate). Review of a Power Wheelchair (PW) or Scooter Safety Skills Assessment Supplement, dated 10/20/25, reflected Resident #1 was safe to use PW or Scooter by OTR A and SLP A. Review of facility Policy & Procedure on Use of a Mechanical Lift, dated 07/01/23, which reflected, 1. Identifies patient/resident and introduces self & co-worker to patient/resident (and family, if appropriate). Event ID: Facility ID: 676382 If continuation sheet Page 3 of 3