Health inspection·December 3, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for 1 of 3 residents (Resident #1) reviewed for discharge summary. The facility failed to complete a recapitulation of stay for Resident #1, who discharged to the community on 10/07/25. This failure could place residents at risk of a recapitulation of their stay being unavailable to help ensure continuity of care once they are discharged from the facility.Findings included: Record review of Resident #1's face sheet dated 10/21/25, indicated a 55yo female who admitted to the facility on [DATE] with diagnoses which included anxiety (excessive worry, fear, and nervousness), chronic kidney disease (kidneys unable to filter waste products from the blood), fibromyalgia (widespread body pain and fatigue), displaced trimalleolar fracture of left lower leg (severe injury to the ankle joint where three of the bones are broken and displaced) and muscle weakness (muscles lose their strength and tone). Resident #1 discharged from the facility on 10/07/25. Record review of Resident #1's discharge MDS assessment dated [DATE], indicated Resident #1's cognition was intact with a BIMS score of 15. Resident #1 was discharged to the community with a discharge assessment-return not anticipated. Record review of Resident #1's comprehensive care plan dated 08/01/25, indicated Resident #1 expressed a desire to return to the community. The care plan interventions included make arrangements with required community resources to support independencepost-discharge. Record review of Resident #1's Discharge Instruction Form, with an effective date of 10/01/2025, reflected it was not complete nor signed. The areas of Follow-up Appointment, Dietary Recommendations, Skin Issues and Patient Instructions/Teaching were all missing required information. Record review of Resident #1's IDT - Recapitulation of Stay, with an effective date of 10/08/2025, revealed the document was not complete nor signed. The areas of Nursing Services, Activities, Dietary Services, and Rehabilitation Services were all missing required information. The only completed section was Social Services. Record review of Resident #1's nursing progress note dated 10/07/25 at 15:21 (3:21 PM) and signed by RN A, revealed . [Resident #1 was discharged today accompanied by his [sic] [family member] with take home meds and discharge instructions. Review of Resident #1's EMR reflected no discharge summary was completed or uploaded. During an interview on 10/21/25 at 2:00 PM, RN A stated when a resident discharged from the facility the discharge summary was completed. RN A said the nurse was responsible for ensuring the nursing summary section was completed. RN A said the discharge summary included the list of medications the resident was taking, home health company, any equipment needed, the summary of their care, and any upcoming doctor appointments. RN A stated the SW informed her on the morning of 10/07/25, that Resident #1 would be discharged the same day. RN A stated she gathered all of Resident #1's medications, recorded her routine vitals and printed the discharge paperwork. RN A stated she completed the recapitulation of the medications and had Resident #1 sign it. RN A stated she failed to make a copy as Resident #1 was in Page 1 of 5 676128 676128 12/03/2025 The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a rush to leave. RN A stated she was supposed to make a copy and place it in the discharge paperwork tray to be scanned into Resident #1's EMR by Medical Records. RN A stated she was supposed to create a Progress Note and enter the details of Resident #1's discharge including when and whom she left with, discharged location, observation, etc. RN A stated she completed discharges before and made copies, except this time Resident #1 was in a hurry. RN A stated she was trained on how to complete discharges by the ADON. RN A stated she never had issues with discharges before. RN A stated she should have copied the discharged paperwork. RN A stated Resident #1's physical and mental health could be jeopardized without the list of medications and details of her stay properly documented. RN A stated it was important for Resident #1 to have a copy of her Discharge Summary completed in case there was an emergency. During an interview on 10/21/25 at 2:35 PM, the ADON stated the SW alerted the nurses which residents were being discharged , the date and time, and the mode of transportation. The ADON stated the nurse gathered all medications and completed the discharge paperwork. The ADON stated the nurse confirmed the discharge with the resident. The ADON stated on the day of discharge, the nurse gathered all medications and informed the resident of the discharge time. The ADON stated the nurse confirmed all medications in the resident's room with the resident and/or family and educated them. The ADON stated the nurse should have printed the discharge form because it included the medication list including the discharged date and had the resident sign it. The ADON stated she instructed the nurses to print two copies to be signed by the resident. The ADON stated you were supposed to enter everything that transpired during the discharge process into the resident's EMR under Progress Notes. The ADON stated RN A knew the discharge process, how to complete the paperwork and to educate the residents on their medications. The ADON said by not completing a discharge properly, residents may not know the time or how to take their medications. The ADON stated if the residents were not alert to understand the medication list, it could lead to the residents taking the incorrect amount. During an interview on 10/21/25 at 3:05 PM, the SW stated she had worked at the facility for six months and she was trained by a peer from one of their sister facilities on Discharges. She stated said they discussed everything required for discharge planning (continuation of care, durable medical equipment, follow-up appointments, referrals, Social Security Income, transportation, etc.). The SW said she was instructed to make sure she initiated all the required paperwork for the discharge so the residents received necessary services. The SW stated as a team it was decided when a resident was medically stable to discharge or if they met their therapy goals. The SW stated a discharge list was sent out to management that included the name of the residents being discharged and it was also discussed during the morning meeting. The SW stated they discussed the confirmed time and day of discharge and communication was shared with the nurses. The SW stated at discharge residents received a discharge form, a list of their medications and any home health information that had been set up. The SW stated she initiated the discharge form and completed her section and nursing was required to complete the rest of the form. During an interview on 10/22/25 at 11:20 AM, the DON stated each department was responsible for completing their section of the discharge summary. The DON reviewed Resident #1's EMR and said there was not a complete discharge summary. The DON said Resident #1's discharge summary should have been completed on 10/07/25, when she discharged from the facility. The DON said not completing a discharge summary in its entirety placed the resident at risk for missing follow up appointments and missed medications. During an interview on 10/22/25 at 2:15 PM, the ADM stated the discharge process was started at admissions during their Circle of Excellence Meetings. The ADM stated they met with the resident and their RP and discussed their expectations, discharge planning and any special services or equipment based on the resident's progress therapeutically. The ADM 676128 Page 2 of 5 676128 12/03/2025 The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the next steps were to touch base with the resident as needed and once the resident decided, they provided a list of other Nursing Homes, Group Homes, or Homeless Shelters. The ADM stated the SW initiated the discharge summary and then each department had a section they were required to complete. The ADM said failure to complete a discharge summary placed the resident at risk for missed follow-up appointments or not knowing what medications they were taking. The ADM stated he would attempt to establish more concrete discharge plans at admissions. Record review of the facility's policy Discharge Summary and Plan with a revised date of December 2016, indicated . 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's:a. Current diagnosis;b. Medical history (including any history of mental disorders and intellectual disabilities); .p. Medication therapy. 3. As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented.13. A copy of the following will be . filed in the resident's medical records:a. An evaluation of the resident's discharge needs;b. The post-discharge plan; andc. The discharge summary. 676128 Page 3 of 5 676128 12/03/2025 The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 and record review, the facility failed to develop and implement a comprehensive person-centered care plan interventions for each resident consistent with the resident rights that included measurable objectives and time frames to meet the resident's medical needs identified in the comprehensive assessment for 1 (Resident #1) of 6 residents reviewed for care planning. The facility failed to care plan Resident #1's wound care order that reflected the following: Allow Pico dressing to stay 1 week, then remove and let doctor know what underlying wound look like. Text picture to [number] in the morning until 10/08/2025. This failure could affect resident care/services and may cause a delay in treatment and/or complications, infection, and poor wound healing. Record review of Resident #1's admission Record, dated 10/16/25, reflected an [AGE] year old-female initially admitted on [DATE] with diagnoses to include Spontaneous Rupture of Extensor Tendons (unexpected and without apparent cause tear of the tendons that extend the fingers and thumb) Left Lower Leg, Strain of Left Quadriceps Muscle, Fascia and Tendon (tear or overstretching of muscle fibers, fascia (connective tissue that wraps around, supports, and separates muscles, organs, blood vessels, and nerves), or tendons in the thigh), Postprocedural Seroma of a Musculoskeletal Structure Following a Musculoskeletal System Procedure (collection of serous fluid that forms after a musculoskeletal system procedure), Difficulty in Walking, and Lack of Coordination (uncoordinated movement due to a muscle control problem). Record review of Resident #1's admission MDS assessment, dated 09/15/25, revealed the resident had a BIMS score of 15 out of 15, which indicated cognition was intact. The MDS assessment under Section GG-Functional Abilities also revealed resident required assistance with walking. The MDS assessment under Section M-Skin Conditions revealed resident was at risk of developing pressure ulcers/injuries. Record review of Resident #1 Comprehensive Care Plan, dated 09/15/25, revealed the care plan did not include focus, goals, and interventions of wounds. Record review of Resident #1's prescription, signed and dated 10/01/25 by [MD] reflected the following: Please allow PICO dressing to stay on for 1 week. Then remove and let us know what underlying wound looks like. Text picture to [number]. Record review of Resident #1's order summary report, dated 10/17/25, reflected the following: Allow Pico dressing to stay 1 week, then remove and let doctor know what underlying wound look like. Text picture to [number] in the morning until 10/08/2025 11:46. Start date: 10/01/2025 and End date: 10/08/2025. In an interview on 10/16/25 at 4:51 PM with DON, she stated Resident #1 came into the facility post-surgery for her knee. DON stated Resident #1 had sutures on her knee. DON revealed the facility only monitored Resident #1's wound. In an interview on 10/17/25 at 2:00PM, LVN B revealed she did not deal with wounds. She stated if there were any changes, she reported it to the nurse. She stated she looked at the treatment and admission report to find the residents' needs. LVN B stated some care plans were important. She stated if there were any changes with the resident, she had to look at the care plan. She also stated if there were no changes or a resident was a long-term care resident, she did not often look at the care plan. LVN B stated the risk of not looking at resident's care plan was not understanding what the resident's needs were. In an interview on 10/17/25 at 2:49 PM with MDS Coordinator, he stated he had worked at the facility for three months. He stated the ADON or Wound Care Nurse was responsible for adding any wound care to care plans. He also stated he had 21 days for the care plan. MDS Coordinator stated acute care plans were done by the ADON. He stated he would help with updating care plans if the Wound Care Nurse was behind. He also stated he could not update the care plan with wound care if the Wound Care Nurse did not tell him. The MDS Coordinator stated he was told on 10/16/25 by DON to add wound care into Resident #1 care plan. He 676128 Page 4 of 5 676128 12/03/2025 The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated not having wound care in the care plan could affect the resident's care. In an interview on 10/17/25 at 3:29 PM, the ADON revealed the facility monitored Resident #1's wound. She stated Resident #1's care plan should have been revised to include any wound care that was provided by the facility. The ADON also stated it was the MDS nurse's responsibility to update Resident #1's care plan. She stated sometimes MDS Nurse may not be in the facility upon a residents' admission but was still responsible. ADON stated the risk of not including the care plan was staff not knowing proper care for the resident In an interview on 10/17/25 at 5:14 PM, Wound Care Nurse stated her understanding was the MDS Nurse oversaw the care plans. The Wound Care Nurse revealed she had been performing wound care for Resident #1 although it was not in the care plan. She stated wound care goals and interventions were supposed to be included in Resident #1's care plan. She revealed the wound care for Resident #1 was not in the care plan due to an oversight. She stated she was responsible for updating care plans of all resident that she saw for wound care. The Wound Care Nurse stated not revising care plans to include new goals was risk of resident's care being affected. In a follow-up interview on 10/17/25 at 5:31 PM, Administrator and DON stated they identified that Resident #1 did not have wounds care planned. The DON stated the MDS Coordinator was responsible for updating care plans. The DON also stated the Wound Care Nurse was responsible for updating care plans to include wounds. She stated the wound nurse was supposed to add to Resident #1's care plan because she was monitoring the resident's wound. DON revealed she was responsible for overseeing that care plans were updated. DON stated the risk of not updating the care plan was residents not receiving the proper care. Record review of the facility's policy titled, Care Plans-Baseline revised March 2022 reflected in part the following: The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following:a. Initial goals based on admission orders and discussion with the resident/representative;b. Physicians orders;c. Dietary orders;d. Therapy services;e. Social services; andf. PASARR recommendation, if applicable. 676128 Page 5 of 5