Health inspection·February 7, 2023

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received food that accommodates resident preferences for one resident (Resident #21) of five residents reviewed for food preferences. The facility failed to ensure Resident #21's likes and dislikes food preferences were honored during the lunch service on 02/06/23. This failure could cause residents who ate meals from the kitchen at risk of not having their choices and food preferences accommodated, possible weight loss, and a diminished quality of life. Findings included: Review of Resident #21's face sheet, dated 02/07/23, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease, chronic kidney disease, and major depressive disorder. Review of Resident #21's undated Quarterly MDS Assessment reflected she had a BIMS score of 15 indicating no cognitive impairment. In an interview on 01/30/23 at 12:00 PM with Resident #21 revealed she loved vegetables but only certain ones. Resident #21 said she had given the kitchen staff a list of her likes and dislikes, including vegetables. Resident #21 said she was still served vegetables she did not like even though her preferences were listed on her meal ticket that came with her tray. In an observation and interview with Resident #21 on 02/06/23 at 12:16 PM revealed she had just received her lunch tray. Resident #21 said she saw the tray had vegetables on it including carrots which she had as dislike on her meal ticket. Resident #21's lunch tray revealed mixed vegetables on it, including carrots. Resident #21's meal ticket revealed no carrot on the top part and was placed on her tray [sic]. Resident #21 said she was not going to be able to eat the vegetables because she did not want to have to pick out all the carrots. In an interview on 02/06/23 at 12:48 PM with the DM revealed the facility used a meal tracker system that was specialized for each person so that their dislikes showed up on their meal tickets. The DM said if for example a resident did not like a certain vegetable it would show up as no and then the vegetable name on the resident's meal ticket. The DM said if the kitchen was serving that vegetable, then they would not put that on the resident's tray. The DM said he did not know that Resident (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: 676237 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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)