Health inspection·December 2, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 4 residents reviewed for pressure ulcers. CNA A and CNA B failed to reposition Resident #1 as required by her orders and care plan on 10/15/25. This failure could place residents with pressure wounds at risk of the wound worsening, leading to increased pain, infection, delayed healing, serious complications including sepsis, reduced mobility, and a lower quality of life.Record Review of Resident 1's admission MDS assessment, dated 09/19/25, revealed she was a [AGE] year-old female, originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cognitive communication deficit, severe protein calories malnutrition, pressure ulcer to the sacrum region, stage IV, needed assistance with personal care. The resident used a Foley catheter. Resident #1's BIMS score was 4 indicating severe cognitive impairment. Resident #1 was understood and was able to understand. The resident was dependent on staff to roll her from left to right. Record Review of Resident #1's Care Plans, dated 09/15/25, reflected,1. Has potential for pressure ulcer development r/t generalized weakness, decreased mobility, history of pressure ulcers, incontinence, poor to variable PO intake. Facility interventions included: Has been refusing repositioning even with education of the importance of repositioning. - educated granddaughter and resident of the risk of further skin breakdown and deterioration of current wound and resident's right to refuse care. Position frequently - resident likes to curl up in bed.2. Resident has current skin concerns: Has stage IV pressure wound of the sacrum. Facility interventions included: Turn and reposition as tolerated. Encourage to turn and reposition, provide assistance as necessary. Record Review of Resident #1's Order Summary Report, dated 09/15/25, reflected: May use mobility bars to aide in easy turning & repositioning while in bed every shift. Review of Resident #1's Wound Evaluation and Management Summary reflected: 10/15/25 Stage IV Pressure Ulcer Sacrum - 5 CM x 4.6 CM x 1.9 CM Wound Progress: Improved evidenced by decreased surface area. An observation and interview on 10/15/25 at 11:54 AM with Resident #1 revealed the resident was in bed. She had an air mattress and head of bed was elevated. Resident #1 had a wound vac that was functioning, and she was lying on her right side. Interview with Resident #1 answered simple questions with a yes and seemed disinterested to speak. When asked if she was repositioned, she did not answer. An interview on 10/15/25 at 1:38 PM with LVN D revealed she was the treatment nurse. LVN D stated she completed all the wound treatments in the facility. She stated on 10/15/25 she completed Resident #1's wound care while the wound care doctor was assessing the wounds in the facility. She stated the resident used a wound vac, and wound care was completed on Monday, Wednesday and Friday. LVN D stated the resident's wound had improved compared to the wound assessment that had been completed the previous week. Resident #1's was admitted with the pressure ulcer at stage IV. LVN D stated staff were expected to Residents Affected - Some Page 1 of 3 676395 676395 12/02/2025 The Healthcare Resort of Plano 3325 West Plano Parkway Plano, TX 75075

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reposition the residents with wounds and who were in bed, to prevent the wounds from getting worse or having a skin breakdown. An interview on 10/15/25 at 3:45 PM with CNA A revealed staffing was sufficient for the morning shift on 10/15/25 . CNA A stated he was assigned to provide care to Resident #1, but he was asked to switch the resident with CNA B because Resident #1 preferred a female aide. CNA A stated he had not repositioned Resident #1 during the morning shift until around 2:30 PM when he assisted CNA B in repositioning and providing incontinent care. CNA A said he always tried to keep his residents repositioned and the DON expected that all residents were repositioned , at least every two hours. CNA A said Resident #1 required two staff to assist with repositioning. CNA A stated the residents were supposed to be repositioned to prevent skin breakdown or from the wounds getting worse. An interview on 10/15/25 at 4:05 PM with CNA B revealed she was assigned for the morning shift on 10/15/25. CNA B stated she was not assigned to Resident #1, she was only asked by the ADON to give her a shower. CNA B stated at around 9:30 AM she went in the room and informed Resident #1 she was going to give her a shower, but the resident declined to take a shower. CNA B stated while she was in the room the therapist personnel came in the room to assist with getting the resident out of bed, but the resident declined to get out of bed. CNA B stated she left the resident's room, and she did not go back until around 2:30 PM when she went to assist CNA A with repositioning the resident and providing incontinent care. CNA B stated residents who were bed bound were to be repositioned every 2 hours to prevent skin breakdown. An interview on 10/15/25 at 4:24 PM with LVN C revealed he was the nurse charge for Resident #1. LVN C stated Resident #1 required two-person assistance with activities of daily living and repositioning in bed. He stated residents who were in bed and not able to change positions in bed, the staff were to assist the residents at least every 2 hours. LVN C stated Resident #1 required two staff to assist with repositioning. He stated he had not been requested, nor had he repositioned the resident during the shift. He stated sometimes the aides would request him to assist with repositioning the resident. LVN C stated he was not aware the resident had not been repositioned during the morning shift. He stated the residents who were in bed and unable to position themselves were to be assisted by the staff in repositioning every 2 hours to prevent skin breakdown, and regarding Resident #1 who had a wound, prevent the wound from getting worse. An interview on 10/15/25 at 4:35 PM with ADON revealed she oversaw residents' care in the facility. She stated it was expected for the residents who were bed bound to be repositioned at least every 2 hours. The ADON stated Resident #1 required two people with activities of daily living and repositioning. The ADON stated she had requested CNA B to give Resident #1 a shower only, but CNA A was to provide the resident with care during the shift. Resident #1 had a pressure wound and required to be repositioned and prevent the wound from getting worse and the resident sustaining skin breakdown. An interview on 10/15/25 at 4:55 PM with the DON revealed she expected the staff to reposition the residents who were in bed and unable to reposition themselves, the residents with wounds were to be repositioned to prevent the wounds from getting worse. The DON stated if Resident #1 refused any care, the aides were to report to the charge nurse and the charge nurse was to inform the resident's responsible party. She stated Resident #1 had a pressure ulcer, and the staff were expected to encourage the resident to change positions throughout the shift. The DON stated she was not aware the resident hadn't been repositioned during the morning shift. She stated the resident had the foley catheter due to the stage IV pressure ulcer and the resident was using the wound vac. The DON stated from the wound care notes, the sacral pressure wound had not deteriorated but rather had improved. Review of the facility policy revised 4/3/35 and titled Activities of Daily Living, reflected The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, 676395 Page 2 of 3 676395 12/02/2025 The Healthcare Resort of Plano 3325 West Plano Parkway Plano, TX 75075

F 0686 ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676395 Page 3 of 3