Health inspection·December 3, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one (Resident #1) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1's room was in a position accessible to the resident on 10/28/2025.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #1's Face Sheet, dated 10/28/2025, reflected the resident was a [AGE] year-old female who admitted on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (progressive cognitive decline, memory loss, and behavioral changes) and muscle wasting and atrophy. Record review of Resident #1's Quarterly MDS Assessment, dated 08/14/2025, reflected moderate cognitive impairment with a BIMS score of 08. Resident #1 required assistance for self-care and mobility needs. Record review of Resident #1's Comprehensive Care Plan, dated 08/01/2025, reflected the resident was at risk for falls related to unsteady gait/balance. One intervention was to keep call light within reach and encourage to ask for assistance. During an observation and interview on 10/28/2025 at 9:27 AM, Resident #1 was lying in bed. The call light was lying on the floor next to her bed. When asked about her call light, Resident #1 replied she could not reach it and asked the surveyor to get it. The DON was in the hall in the time. She came into Resident #1's room and observed the call light on the floor. The DON clipped Resident #1's call light to her blanket within the resident's reach. Upon exiting the room, the DON stated she was in Resident #1's room before the surveyor entered and Resident #1 was holding the call light in her hand. The DON stated the resident's call light should always be available to the resident to notify staff of any needs. During an interview on 10/28/2025 at 10:20 AM, CNA B stated at the beginning of her shift and during rounds, she checked to ensure residents had their call lights within reach. She stated it was important for Resident #1 to have her call light in reach to be able to call for help. She stated if something happened, no one would know. During an interview on 10/28/2025 at 10:26 AM, LVN A stated it was important for Resident #1 to have her call light in reach. He stated it was important for Resident #1 and all residents to be able to communicate with staff when they needed something. During an interview on 10/28/2025 at 2:11 PM, the Administrator stated every resident should have their call light placed where they could reach it. He stated it was important to ensure call lights were always within reach so residents could get help when they needed it. Record review of the facility's policy, Answering the Call Light, revised September 2022, reflected The purpose of this procedure is to ensure timely responses to the resident's requests and needs.Ensure that the call light is accessible to the resident when in bed. Residents Affected - Few Page 1 of 2 676363 676363 12/03/2025 Mustang Park Therapy and Living Center 4501 Plano Parkway Carrollton, TX 75010

F 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 (Resident #2) residents reviewed for infection control.The facility failed to ensure CNA C performed hand hygiene between touching Resident #2's curtain with her bare hand and putting on gloves to apply a clean brief 10/28/2025.This failure could place residents at risk of cross-contamination and development of infections.The findings included:Record review of Resident #2's Face Sheet, dated 10/28/2025, reflected the resident was an [AGE] year-old female who admitted on [DATE]. Resident #2 had diagnoses which included hypertension (high blood pressure), hyperlipidemia (blood has too many lipids, or fats), and vascular dementia (decline in mental ability caused by reduced blood flow to the brain). Record review of Resident #2's Quarterly MDS Assessment, dated 10/23/2025, reflected intact cognition with a BIMS score of 13. Section H (bladder and bowel) indicated Resident #2 was always incontinent of bowel and bladder. Record review of Resident #2's Comprehensive Care Plan, dated 10/02/2025, reflected Resident #2 was incontinent. Interventions included to check the resident every two hours and assist with toileting as needed, and provide care after each incontinent episode.During an observation and interview on 10/28/2025 at 10:48 AM, CNA C provided incontinence care for Resident #2. Resident #2 was lying in bed and gave consent for the surveyor to observe care. CNA C pulled the curtain around the bed to provide privacy. CNA C used hand sanitizer and put on gloves. CNA C pulled down the front of Resident #2's brief and cleaned her, using a single wipe for each pass. CNA C used hand sanitizer when she changed gloves. Resident #2 rolled to her left side. CNA C removed the soiled brief from under Resident #2 and dropped it in the wastebasket. CNA C removed her gloves and used hand sanitizer. CNA C moved the curtain to get gloves from a box on the wall in the resident's room. She pulled the curtain to the side when she returned to the resident's bed. CNA C did not use hand sanitizer before she put on clean gloves. CNA C cleaned the resident's bottom and placed a clean brief under her. Resident #2 rolled to her back and CNA C secured the brief in front. CNA C removed her gloves and used hand sanitizer. After exiting the room, CNA C stated the curtain was probably dirty and she should have used hand sanitizer before putting on gloves to care for Resident #2. She stated it was important to use appropriate hand hygiene for infection control. In an interview on 10/28/2025 at 11:01 AM, the DON stated CNA C should have washed her hands or used hand sanitizer before and after each glove change. The DON stated there can be bacteria on curtains and it was important to decrease the risk of infection. During an interview on 10/28/2025 at 11:06 AM, LVN A stated CNA C should have sanitized her hands before putting on gloves and after removing the gloves. He stated that was universal precautions and proper hand hygiene was the most effective way to prevent the spread of bacteria. He stated the facility recently had an in-service on hand hygiene. Review of the facility's policy Handwashing/Hand Hygiene, revised October 2023, reflected This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Perform hand hygiene before applying non-sterile gloves.when removing gloves. perform hand hygiene.The use of gloves does not replace hand washing/hand hygiene. Residents Affected - Few 676363 Page 2 of 2