Health inspection·May 29, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to submit and complete accurate request and recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report for a low air loss mattress within 20 days after the IDT meeting for one (Resident #1) of three residents reviewed for PASRR services. The facility did not submit a complete and accurate request for a low air loss mattress for Resident #1 within 20 days after the Interdisciplinary Team (IDT) meeting held on 12/20/2024. The past noncompliance began on 12/20/2024 and ended on 03/17/2025. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. Findings included: Record review of Resident #1's MDS assessment, dated 02/24/2025, revealed he was admitted to the facility on [DATE] with diagnoses of Dementia without behavioral disturbances, Major Depressive Disorder, Mild Intellectual Disabilities, Pervasive Developmental Disorder, and other medical concerns. The MDS indicated Resident #1 had BIMS of 3, which indicated severe cognitive impairment. The resident required limited assistance performing ADL's, bathing, dressing, toileting, and was a 1-person transfer. Further review of the MDS reflected Section A [1500] resident was considered a PASRR level 2 with Serious mental and intellectual disability. Record review of Resident #1's PASRR record revealed he was assessed for Durable Medical Equipment (DME) on 12/20/2024. The facility was able to secure a Protekt Aire 6000 AB, low air loss mattress for the Resident on 01/16/2025. Record review of Resident #1 care plan dated 05/02/2025 revealed the resident was provided with a low air loss mattress on 03/17/2025. Record review of Resident #1's revised care plan, dated 11/03/2024 with updates, reflected Resident #1 had not received a recommendation for a PASRR Habilitation services DME (Low Air Loss Mattress) for PASRR positive diagnosis of IDD. In an interview on 05/27/2024 at 11:00 a.m. the Administrator said the facility had issues with (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 05/29/2025 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)