Inspection·September 25, 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 interviews and record review, it was determined the facility failed to ensure that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, and readily accessible for 2 of 15 residents reviewed for clinical records (Resident #18 And Resident #20) in that: 1. The facility failed to ensure Resident #18's oxygen therapy was documented in her care plan. 2. The facility failed to ensure the correct interventions were documented in Resident #20's care plan relating to his hydration and cardiovascular health. The facility's failure placed residents requiring care at risk for incorrect or omitted treatment, duplicated treatments, poor self-esteem and self-worth, and a failure to ensure continuity of care. Findings included: Record review of Resident #18's face sheet dated 09/24/24 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's disease, personal history of Covid 19, chronic obstructive pulmonary disease and hypertensive heart disease with heart failure. Record review of Resident #18's Annual MDS assessment dated [DATE] reflected Resident #18 had a BIMS score of 00 out of 15 indicating she had severe cognitive impairment. The MDS Assessment revealed she received oxygen therapy. Record review of Resident #18's revised care plan dated 08/30/2024 did not have any documentation related to oxygen therapy. Record review of Resident #18's active physician orders revealed resident may use oxygen @ 2 liters per nasal canula as needed for shortness of breath. Record review of Resident #20's face sheet dated 09/24/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] had diagnoses that included but not limited to type 2 diabetes, mellitus without complications, chronic kidney disease and congestive heart failure. Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed Resident #20 had a BIMS score of 15 out of 15 indicating his cognition was intact. (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 3 Event ID: 676461 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 676461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country View Living 701 Butler Blvd. Dimmitt, TX 79027 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)