Health inspection·January 21, 2025

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 provide care and services in accordance with the comprehensive assessment of a resident and consistent with the resident's needs and choices for activities of daily living including toileting for one (Resident #1) of four residents reviewed for ADL assistance. Residents Affected - Few CNA A failed to provide Resident #1 with a bedpan for toileting and instead told the resident to use her brief on 12/04/24. This failure could place residents at risk of feeling uncomfortable, disrespected, have a decreased self-esteem and a diminished quality of life. Findings included: Record review of Resident #1's Nursing Home Comprehensive MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with a principal diagnosis of a fracture of shaft of the left femur. The resident had a BIMS score that reflected the resident was cognitively intact. The MDS did not reflect the resident needed assistance with toileting. Record review of Resident #1's Progress Notes dated 11/29/24 reflected: Continent of bowel and bladder. Uses bedpan. Extensive assists x 1 person with ADLs, per LVN C. Interview on 01/21/25 at 1:50 PM with Resident #1 revealed she was told to use her brief when she used her call light to ask for assistance for toileting. Resident #1 stated she could not walk and required a bedpan. Resident #1 also stated CNA A came into her room to respond to her call light on 12/05/24. Resident #1 said she was told by CNA A to use her brief because she did not have time to assist her. Interview on 01/22/25 at 9:36 AM with LVN B revealed she had not personally heard any staff tell a resident to use their brief instead of assisting with toileting the resident. LVN B stated she was told by Resident #1 that CNAs told her to use her brief because the aide did not have time to get a bedpan and assist the resident. LVN B said Resident #1 did not give her a specific name of a CNA. LVN B stated she did not report the incident because Resident #1 did not give her a specific name of a CNA. LVN B stated this was not the correct protocol, and the aide should have assisted the resident by providing her with a bedpan. LVN said if a resident must use her brief as told by a CNA, this was a dignity issue and could lead to skin breakdown. LVN B revealed the last time she was in-serviced on ADLs was upon her hire. (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: 676249 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 676249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Carlyle at Stonebridge Park 170 Stonebridge Lane Southlake, TX 76092 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)