Health inspection·March 22, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 3 of 9 residents (Resident #1, #20 and #21) reviewed for accommodation of needs in that: Residents Affected - Some The facility failed to ensure that Resident #1, #20 and #21's call lights were in reach. This failure could affect all residents who needed assistance and could result in needs not being met. Findings included: Record review of Resident #1's Face Sheet, dated 3-21-2024, indicated a [AGE] year-old-female admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of osteomyelitis (inflammation of bone or bone marrow, usually due to infection), multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), sepsis (a life-threatening complication of an infection), and glaucoma (a group of eye conditions that can cause blindness). Record review of Resident #1's MDS, dated [DATE], revealed a BIMS score of 3 indicating severe cognitive impairment and visual impairment. Resident #1's MDS further revealed Resident #1 rated a score of 1 for functional abilities indicating Resident #1 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity and/or, the assistance of 2 or more helpers is required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. In an observation/interview, on 3-20-2024 at 11:10 AM, revealed Resident #1 was observed lying in bed and awake. Resident #1 was observed to not have her call light within reach. Resident #1's call light was observed to be 3 to 4 feet away from the bed on top of a refrigerator. Observation of the call light revealed it was a pressure call light, with a wide base, used for residents who cannot press a traditional call light button. Observation of Resident #1's hands revealed they were contracted. Resident #1 said she can use the call light but did not know where it was. Resident #1 was only able to speak very softly. In an observation/interview on 3-20-2024, at 11:15 AM, it was revealed that it took RN A, 2 minutes to untangle Resident #1's pressure call light cord, behind the refrigerator in Resident #1's room, for the call light to be able to reach Resident #1's bed. After Resident #1's call light was put within reach of Resident #1, Resident #1 said she can use the call light and pressed the call light (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 4 Event ID: 675811 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 675811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035 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)