Health inspection·June 18, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurate for 4 (Residents # 1, #2, #3, and #4) of 10 resident records reviewed. The facility failed to ensure the MAR for Residents #1, #2, #3, and #4 from 06/01/24 to 06/18/24 accurately reflected the administration of pain medications. This failure could cause residents to receive additional dosages and provide an inaccurate picture of the resident's helath to the physician. Findings included: Review of Resident #1's undated admission Record reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included osteoarthritis (most commont type of athritis which causes joint pain, stiffness, and swelling) of the right shoulder with removal of the joint replacement, diabetes, and high blood pressure. Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Review of her Pain Assessment indicated the resident had taken pain medications but was not currently having any pain. Review of Resident #1's care plan, dated 05/02/24, reflected she had a surgical wound from removal of hardware from her right shoulder. She was not at risk of pain related to the surgery. Interview on 06/18/24 at 11:20 AM with Resident #1 revealed her pain was well controlled. She stated she required pain medication once or twice a day. Review comparison of Resident #1's NAR to her MAR reflected on 06/13/24, 06/14/24, and 06/18/24 Tylenol with Codeine had been removed but not documented on her MAR as being given to the resident. Review of Resident #2's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included kidney failure, heart failure, asthma, and emphysema (a lung condition that causes shortness of breath and reduces the amount of oxygen in the blood). Review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score of 15 indicating she (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: 455763 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 455763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Bend Rehabilitation and Healthcare Center 301 Huguley Blvd Burleson, TX 76028 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)