Health inspection·December 28, 2023

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to establish and implement policies addressing resident admission to the facility for one (Resident #1) of three residents reviewed for admissions in that: Resident #1 was not provided a signed admission agreement or information upon admission to the facility on [DATE]. Resident was discharged on 12/26/23 without a signed admission agreement. This failure could affect residents by placing them at risk for not being aware of what services the facility is providing. Findings included: Record Review of Resident #1's face sheet dated 12/28/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and discharged on 12/26/23. Resident #1's diagnoses included hyperlipidemia (high cholesterol), hypertension (high blood pressure), diverticulosis (inflammation or infection in one or more small pouches in the digestive tract), chronic diastolic congestive heart failure (heart's main pumping chamber becomes still and unable to fill properly) and dysphagia (difficulty swallowing). Record Review of Resident #1's electronic clinical record revealed the admission MDS assessment was in progress and was incomplete. Resident #1's baseline care plan did not reveal Resident #1's cognition. Record review of Resident #1's electronic clinical record revealed no completed or signed admission agreement on file. Interview on 12/28/23 at 11:28 AM with the admission Coordinator revealed it was her responsibility to complete admission agreements with all residents upon admission, including Resident #1. The admission Coordinator confirmed the facility did not have any admission paperwork or agreements for Resident #1 including they did not have a power of attorney. The admission Coordinator stated she did not know the facility's timeframe for completing the admission paperwork or agreements. The admission Coordinator stated the importance of the admission paperwork was to ensure the family members were aware of the facility's policies and procedures. Interview on 12/28/23 at 11:45 AM with the Administrator revealed it was solely the responsibility of the admission Coordinator to have admission paperwork completed within 2-3 days of the admission, the basic resident information should be started at the time of admission, was a digital process (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: 676349 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 676349 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accel at Willow Bend 2620 Communications Parkway Plano, TX 75093 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)