F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on,
interview and record review the facility failed to develop a baseline care plan within 48 hours of admission
for 2 of 5 residents reviewed for baseline care plans, (Resident #'s 1 and 2).
Resident # 1 was admitted on [DATE] and did not have a baseline care plan.
Resident #2's family did not receive a written summary of his baseline care plan.
This failure could affect residents by the facility not having the minimum healthcare information necessary
to properly care for the resident immediately upon their admission.
Findings Included:
Record review of Resident #1's face sheet revealed he was a [AGE] year-old, male with an admission date
of 11/02/2023.
Record review of Resident #1's Diagnosis list revealed the following diagnoses: Atrial fibrillation (an
irregular heart rhythm that causes the heart to beat to beat too quickly which leads to the development of
blood clots that can cause a stroke) Pain, Cerebral infarct (stroke), Stage 3 kidney disease (classified as
moderate damage to the kidneys), hyperglycemia (too much sugar in the blood), know as high blood
sugar), dysphagia (difficulty swallowing), and dementia (decreased cognitive function, and Pain. The list
indicated Resident #1 was a full code.
Record review on 11/06/19 at 12:20 PM, revealed no baseline care plan in rResident #1', s chart and no
comprehensive care plan.
Record review of Resident 2'''s face sheet revealed he was a [AGE] year-old, male with a most recent
admission date of 07/12/2023. Resident #2 had the following diagnoses: Parkinson's disease (a disease of
the central nervous system that affects movement and brain function, Alzheimer's Disease and, Diabetes (a
disease resulting in too much sugar in the blood
Record review on 11/06/19 at 12:20 PM, revealed no baseline care plan in Resident #2's chart, there was
no documentation that Resident #2's responsible party received of a written summary of his baseline care
plan.
An interview on 11/06/23 at 11:00 AM,Resident #2's RP revealed she did not receive a written summary of
the resident's baseline care plan on admission which she stated resulted in her not knowing the
(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:
676499
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
676499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springtown Park Rehabilitation and Care Center
201 Williams Ward Rd.
Springtown, TX 76082
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)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
resident was not his Alzheimer's medication. She stated his cognitive status had declined. She stated she
felt this could have been prevented if she been a part of his care plan process at the time of admission.
An interview with the DON on 11/06/23 at 1:00 PM, revealed she was not sure who is responsible for
initiating the baseline care plan. She stated she was not aware that a baseline care plan should be
completed within 48 hours if the admission occurred on a Friday, or over the weekend. She stated the
weekend supervisor should do it if the resident comes in on the weekend. She stated she is not sure what
the facilities policy is regarding responsibility for initiating baseline care plans. She stated the residents
medications should be reconciled with the resident, the family, and the physician at the time of admission
as a part of the baseline care plan process. She stated she did not know the resident and responsible party
should be given a written summary of the baseline care plan.
Interview with ADON on 11/06/2023 at 1:15 PM, revealed she did not know until today that a baseline care
plan should be done within 48 hours of admission to the facility or that the family should be provided a
written summary of the baseline care plan. She stated she knew she was responsible for doing the baseline
care plans, but thought she had until the following Monday if the resident was admitted on Friday. She
stated she was working on Resident #1's baseline care plan now but had not completed it at the time of the
interview. She stated she had been doing the care plans from Fri, Sat, or Sundays when she returns to the
facility on Monday. She stated she was not familiar with the facilities policy on baseline care plans.
The DON provided the following policy titled Care Plans - Baseline, dated as revised in March 2022
revealed the following in part:
A baseline care plan to meet the resident's immediate health and safety needs is developed for each
resident within 48 hours of admission. The baseline care plan includes instructions needed to provide
effective, person-centered care of the resident that meet professional standard of quality of care and must
include the minimum healthcare information needed to properly care for the resident
The resident and resident representative are provided a written summary of the baseline care plan that
includes but is not limited to a summary of medications, any treatments, or services to be provided for the
resident and the stated goals and objectives of the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676499
If continuation sheet
Page 2 of 2
