Health inspection·June 5, 2025

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 observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that included measurable objectives and time frames to meet the resident's medical, nursing, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #1) of 4 residents reviewed for care plan review and revision. The facility failed to review and revise Resident #1's care plan after a fall on 05/06/2025 and a fall with major injury on 05/13/2025. This failure could affect all residents and contribute to residents not receiving the care and services they needed to prevent falls. The findings included: Record review of Resident #1's Face Sheet, dated 06/05/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 initially admitted to the facility on [DATE] with diagnoses which included Alzheimer's (loss of memory and cognitive ability that interferes with daily life) disease, diabetes (high blood sugar), lumbosacral disc degeneration (spinal disks of lower back break down) with discogenic (between vertebrae of spine) back pain, and atherosclerotic (hardening of arteries) heart disease. Record review of Resident #1's Quarterly MDS (tool used to measure health status) Assessment, dated 05/23/2025, reflected the resident had severely impaired cognition with a BIMS (tool used to assess cognition) score of 00. Section J (active diagnoses) reflected Resident #1 had a fall with major injury. Section I (active diagnoses) reflected Resident #1 was treated for a left femur (bone in upper leg) closed fracture with routine healing. Record review of Resident #1's Comprehensive Care Plan, dated 05/06/2025, reflected a fall risk focus related to unsteady gait/balance, poor cognition regarding safety, and a history of falls. This focus area had an initiation date of 02/13/2024 and a revision date of 03/21/2025. The care plan did not reflect the resident's two recent falls. An intervention was not added to the care plan after each fall. During an observation and interview on 06/05/2025 at 9:47 AM, Resident #1 was lying in bed with the head of the bed slightly elevated. Resident #1 stated she fell a while ago but did not remember how it happened. Page 1 of 2 675113 675113 06/05/2025 The Park IN Plano 3208 Thunderbird LN Plano, TX 75075

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/05/2025 at 3:20 PM, the Interim MDS Coordinator stated a resident's care plan should be updated after a fall. She stated she worked in the facility 3 days a week and updated care plans based on the MDS report. She stated the DON also updated care plans. The Interim MDS Coordinator opened the resident's chart and stated the resident's fall risk care plan was not updated after the resident fell on [DATE] and 05/13/2025. She stated all fall risk interventions were included in the resident's care plan prior to the recent falls. She stated one fall risk intervention was for the therapy department to evaluate the resident after each fall. She stated therapy always evaluated residents after a fall to assess gait and safety awareness. She stated she would ask how to update a fall risk care plan when all fall interventions had been used. During an interview on 06/05/2025 at 3:55 PM, the DON stated care plans were updated after a resident fell. She stated it was important to do this because it reflected the resident's needs and their plan of care. The DON stated she did not update Resident #1's care plan because it already included all fall risk interventions. She stated she would find out what to do next and ensure the care plan was updated. During an interview on 06/05/2025 at 4:15 PM, the Administrator stated an intervention should be added each time a resident falls. He stated the resident's fall risk care plan included all interventions and he was unsure of what could have been added. The administrator stated the facility did not have an acute care plan policy. Record review of the facility's policy, Comprehensive Care Planning, undated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This care plan also reflected Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan. Undated. 675113 Page 2 of 2