Health inspection·September 17, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care. Residents Affected - Some The facility failed to follow physician orders for daily fasting blood sugar checks for Resident #1 on 09/03/24, 09/04/24, 09/09/24, 09/10/24, 09/15/24, and 09/16/24. This failure could place the resident at risk of not receiving the care intended by the physician. The findings included: Record review of Resident #1's face sheet, printed on 09/17/24, reflected a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of legal blindness, chronic obstructive pulmonary disease (disease causing restricted airflow and breathing problems), diabetes mellitus due to underlying condition with diabetic neuropathy (a chronic disease that occurs when the body can't regulate blood sugar levels), other sequelae of cerebral infarction (Alteration of sensation following a stroke), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis that affects only one side of the body following a stroke), and chronic kidney disease (progressive damage and loss of function in the kidneys). Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 14, which indicated Resident #1 was cognitively intact. Section GG - Functional Abilities and Goals, question GG0130. Self-Care indicated Resident #1 required moderate assistance with ADLs of toileting, showering, and personal hygiene. Record review of Resident #1's care plan, revised on 08/28/24, reflected the following: .FOCUS: The resident has Diabetes Mellitus with neuropathy . INTERVENTIONS: Fasting Serum Blood Sugar as ordered by doctor . Record review of the physician orders tab of Resident #1's electronic health record revealed an order, dated 08/28/24 to CHECK FBS EVERY AM in the morning, with a start date of 08/29/24. Record review of Resident #1's September medication administration record indicated Resident #1's blood sugar was not checked on the mornings of 09/03/24, 09/04/24, 09/09/24, 09/10/24, 09/15/24, and 09/16/24. (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: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy Dallas, TX 75215 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)