Inspection·January 25, 2024

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 observation, interview, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one of five residents (Resident #15) reviewed for reasonable accommodations. Residents Affected - Few The facility failed to provide assistance to Resident #15 after answering her call light. This failure could place residents at risk of not being able to contact staff and their needs not being met. Findings included: Record review of Resident #15's quarterly MDS Assessment, dated 11/14/23, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: heart failure, hypertension, renal insufficiency, septicemia, diabetes, hyperlipidemia, cerebrovascular accident, Non-Alzheimer's dementia, anxiety disorder, and depression. Her BIMS score was 7 out of 15, which revealed she was severely cognitively impaired. Record review of Resident #15's care plan, undated, reflected resident was at risk of dehydration. Interventions included assist with fluids as needed, encourage oral rehydration, and offer fluids between meals and with medications. Observation of Resident #15's room on 01/24/24 at 11:00 AM revealed she was on isolation precautions for COVID-19. Her door was open, and she was observed laying in her bed. Her call light was on. LVNA and CNA B asked the state surveyor to answer Resident #15's call light. LVN A walked to Resident #15's door and did not come inside. LVN A asked the state surveyor to answer Resident #15's call light. LVN A informed the state surveyor a CNA would come inside the room to check on Resident #15. CNA B walked to Resident #15's door and did not come inside. CNA B asked the state surveyor to answer Resident #15's call light. CNA B waited approximately two minutes then came inside Resident #15's room to answer the call light. After leaving Resident #15's room, CNA B informed LVN A she was going on a break. Interview with Resident #15 on 01/24/25 at 11:06 am revealed she was on isolation precautions for COVID-19. She stated she turned her call light on to request hot tea to help soothe her sore throat. She stated CNA B came inside her room to answer her call light. She stated CNA B asked her what assistance was needed. Interview with Resident #15 on 01/25/24 at 2:35 pm revealed she did not receive the hot tea she (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 3 Event ID: 676388 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 676388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Creekwood 2100 Cannon Dr Mansfield, TX 76063 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)