Health inspection·February 25, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 4 residents reviewed for accuracy of medical records. The facility failed to ensure the nursing notes accurately reflected Resident #1's condition when the ADL sheet incorrectly documented a rash on 01/03/2025 to her buttocks . These failures could place residents at risk for medication and /or treatment errors and omissions in care. Findings included: Review of Resident #1's electronic face sheet printed 02/25/2024 revealed an [AGE] year-old female admitted to the facility initially on 12/30/2024 with diagnosis that included but not senile degeneration of brain (decline in an individual's memory, behavior, and cognitive abilities). Review of Resident #1's admission MDS dated [DATE] revealed a BIMS score was not completed. Review of Resident #1's care plan revised 01/02/2025 revealed skin integrity issues as skin tears and intervention to include turn/ reposition and complete skin checks. Review of Resident #1's point of care history form dated 12/30/2024-01/05/2025 indicated rashes on the buttocks documented by CNA A on 01/03/2505 at 11:09PM. Review of nursing notes dated from 12/30/2024-01/04/2025 revealed no documentation of skin issues. Interview on 02/25/2025 at 1:05 PM with the Wound Nurse revealed nurses reviewed shower sheets daily and if the CNAs indicated any skin issues, then the nurse would let her know and she would assess the resident. The Wound Care Nurse stated she was not informed of any skin issues for Resident #1 during her stay. The Wound Care Nurse stated a shower sheet was not completed by CNA A on 01/03/2025 because shower sheets were not completed during the night shift. The Wound care nurse stated she also discharged Resident #1 and did not notice any skin issues upon discharge assessment. In a phone interview on 02/25/2025 at 2:50 PM with CNA A revealed she did not remember details about Resident #1 but stated she may have clicked that rashes were present by mistake. (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: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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)