Inspection·July 26, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to inform resident in advance, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option for 1 (Resident #1) of 5 residents reviewed for resident rights in that: Residents Affected - Few LVN A failed to obtain a signed consent prior to Resident #1 receiving psychoactive medication Sertraline HCl (a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs) used to manage and treat the major depressive disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, premenstrual dysphoric disorder, and social anxiety disorder) on admission. This failure could affect all residents receiving antidepressant medications potentially voiding their opportunity to make choices about their care. Findings include: Record review of Resident #1's face sheet dated 05/26/23 revealed a [AGE] year-old male admitted to the facility. His diagnoses included dementia with agitation, Alzheimer's, anxiety disorder, impulse disorder, and depression. Record Review of Resident #1's Quarterly MDS dated [DATE] indicated antidepressant medication to be prescribed by physician and revealed a BIMS score of 1 indicating the resident is severely impaired for cognition. Record Review of Resident #1's care plan dated 07/07/23 indicated antidepressant medication as prescribed by physician. The care plan reflected facility staff would educate the resident/family/caregivers about risks, benefits, and the side effects. Record review of Resident #1's Physician orders dated 05/27/23 revealed orders for: Sertraline HCl Oral Tablet 25 mg, Give 1 tablet by mouth in the morning related to depression. Record review of Resident #1's MAR revealed he received Sertraline HCl Oral Tablet 25 mg from 05/27/23 through 07/20/23. Review of Resident #1's EMR on 07/25/23 revealed no consent documented for Sertraline HCl. Record review of the facility copy of Resident #1's durable POA dated 04/20/23 reflected he had a (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 2 Event ID: 675196 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 675196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Park Health and Rehabilitation Center 1720 N McDonald McKinney, TX 75069 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)