Inspection·December 18, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's Comprehensive Care Plan, dated 10/13/2024, reflected no care plan for oxygen therapy. Observation on 12/18/2024 at 10:09 AM revealed Resident #1 was not inside the room. It was noted that there was an oxygen concentrator at the resident's bedside. Residents Affected - Few In an interview with LVN A on 12/18/2024 at 11:09 AM, LVN A stated the resident was in therapy. She said the resident had respiratory failure that was why there was a stand-by oxygen concentrator inside his room. She said the resident would not usually use it. Observation and interview with the DON on 12/18/2024 at 12:54 PM, the DON stated every resident needed a comprehensive care plan to make sure the residents received the applicable and appropriate care needed. She said the purpose of the care plan was to make sure the staff would be on the same page when providing care. She said the care plan should be resident-centered and should show what specific care the resident needed. She turned her computer, looked at Residents #1's care plan section and saw he did not have care plan for oxygen. She said the resident had a diagnosis of respiratory failure, had an oxygen concentrator inside the room, had an order for oxygen, then he should have a care plan for oxygen. She said she would make one for Resident #1. She said without the care plan, the staff could have confusion with regards to the resident's care. She said, the MDS Nurse was sick and she was responsible in doing and overseeing the care plans of the residents. She said the expectation was for all residents to have a complete and detailed care plan. She said she would check if those residents that were using oxygen had care plans for oxygen therapy. In an interview with the Administrator on 12/18/2024 at 1:26 PM, the Administrator stated all the residents should have a care plan appropriate to their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. The Administrator concluded that the expectation was for the staff to ensure that the residents were care planned accordingly. She said since the MDS Nurse was sick, the DON was responsible in doing the care plan. 2. Review of Resident #20's Face Sheet, dated 12/18/2024, reflected Resident #20 was an [AGE] year-old female admitted on [DATE]. Resident # 20 had a diagnosis of dementia and respiratory failure. Review of Resident #20's Quarterly MDS (tool used to measure health status) Assessment, dated 12/05/2024, reflected a BIMS (tool used to measure cognitive status) Assessment was not conducted because resident was rarely/never understood. Section C reflected was severely impaired related to cognitive skills for daily decision making. The Quarterly MDS Assessment was completed prior to the order of oxygen therapy and isolation precautions and does not reflect these. Review of Resident #20's Comprehensive Care Plan, dated 09/20/24, did not reflect any care plan for administration of oxygen and droplet precautions status for a respiratory illness. An observation 12/18/24 at 09:25 AM revealed a sign on the outside of Resident #20's door instructing to follow droplet precautions when in the room. A plastic unit with drawers was sitting outside Resident #20's door and stocked with PPE items (protective equipment worn to prevent the spread of infection). This surveyor used hand sanitizer and put on PPE items prior to entering Resident #20's room. Resident #20 was the only resident in that room and observed lying in bed asleep. An oxygen concentrator was next to the resident's bed and the Resident #20 was receiving oxygen at 2 liters per (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN Plano, TX 75075 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 0656 Level of Harm - Minimal harm or potential for actual harm minute. PPE was removed and discarded in a trash bin near the door. Hand hygiene was performed in Resident #20's restroom before exiting the room. Record review of Resident #20's physician's order, dated 12/10/24, reflected to administer oxygen at 2 liters via nasal cannula. Residents Affected - Few Record review of Resident #20's progress note, dated 12/13/24, reflected Resident #20 tested positive for RSV (virus that infects the respiratory tract and lungs) and was placed on droplet precautions. During an interview on 12/18/24 at 11:40 AM, the DON stated Resident #20 tested positive for RSV over the weekend and was placed on droplet precautions. The DON reviewed Resident #20's electronic medical record and stated the care plan should have included Resident #20 used oxygen and was on droplet precautions for RSV. The DON stated the MDS Coordinator was responsible for overseeing the care plans but had been out for a couple of weeks due to illness. The DON stated it was important for residents to have a care plan that reflected their needs, so everyone knew how to care for the residents. She stated that information was also included in the care plan meeting to let the family know how staff was providing care for their loved one. Review of facility's policy Comprehensive Care Planning reflected The facility will establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. Undated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 3 of 3