Health inspection·February 19, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interview, observation, and record review, 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 timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents, (Resident #1) reviewed for care plans. 1. The facility failed to follow the care plan dated 07/05/24 when staff failed to ensure a pillow was always under Resident #1's feet who had a DTI to the heel, while she was in the bed on 02/19/25. This failure could place residents at risk of not receiving the necessary care and services. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female, with an initial admission date of 04/06/23, and a re-admission date of 02/18/25. Resident #1 had a diagnosis of non-traumatic acute subdural hemorrhage (blood leaks between the brain and the skull), Type 2 Diabetes (body does not use insulin properly or produce enough insulin), Hypothyroidism (thyroid gland does not produce enough thyroid hormone), Muscle weakness, Chronic Kidney Disease, Wedge Compression Fracture (spinal fracture), Dementia (loss of memory and other mental capabilities), and Arthritis (joint inflammation and damage). Record review of Resident #1's Quarterly MDS Assessment, dated 12/26/24, reflected Resident #1 had a BIMS score of 3, which meant Resident #1 had a very low level of cognition. The MDS also noted Resident #1 did not display any behavioral symptoms like threatening others, screaming, cursing at others, hitting, scratching, pacing, or rummaging. The MDS noted Resident #1 did not display and rejection of care. Pressure ulcers were listed under skin conditions on the MDS quarterly assessment. Record review of an active physician's order, dated 08/05/25 reflected the following: Order Summary: Off load both heels with pillow while patient in bed at all time (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 8 Event ID: 675447 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 675447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243 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)