Park Manor of McKinney

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported, immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for reporting allegations of abuse. The facility nursing staff failed to identify, assess and report a skin injury to Resident #1's lower left extremity from 7/10/26 to 7/22/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident or the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for one of two residents (Resident #1) reviewed for discharge notices. The facility failed to notify Resident #1 in writing of his transfer/discharge to home due to his behaviors of exit seeking, the reason for the discharge, the right to appeal and they failed to send a copy of the notice to the Ombudsman as soon as practicable. This failure could place residents at risk of being transferred or discharged , and not having access to available advocacy services, discharge/transfer options, and appeal processes.

Inspectors wroteBased on observation, interview and record review, the facility failed to promptly notify the resident's physician, physician's assistant, nurse practitioner, or clinical nurse specialist of results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physicians' orders for one of three residents (Resident #1) reviewed for notification. 1. The facility failed to notify Resident #1's primary Physician and Infectious Disease Nurse Practitioner for three days when Resident #1 tested positive for C. Diff on 04/19/24. (Per CDC website: C. diff is a bacterium that causes diarrhea and colitis (an inflammation of the colon). Most cases of C. diff infection occur when a resident is taking an antibiotic or not long after resident has finished taking antibiotics. C. diff can be life-threatening. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to 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 two (Residents #1 and Resident #6) of four residents observed for infection control. 1. The facility failed to place Resident #1 who tested positive Clostridioides difficile (C. Diff) on 4/19/2024 in isolation until 04/22/2024, three days after the positive C. Diff result were obtained. (Per CDC website : C. diff is a bacterium that causes diarrhea and colitis (an inflammation of the colon) .Most cases of C. diff infection occur when a resident is taking an antibiotic or not long after resident has finished taking antibiotics. C. diff can be life-threatening. Some of the C. Diff risk factors included: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #15, #20, and #40) of three residents reviewed for respiratory care. 1. The facility failed to ensure Resident #15's nebulizer mask was properly stored. 2. The facility failed to ensure Resident #20's nasal cannula tubing and humidity bottle were labeled or dated. 3. The facility failed to ensure Resident #40's nasal cannula tubing were labeled or dated. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 2 of 5 (Resident #7, Resident #42) residents reviewed for resident rights. The facility failed to promote Resident #7 and 42's right to communication with kitchen staff who primarily spoke Spanish and little to no English. This failure could affect all residents who communicate food and snack requests, verbally and written, by contributing to unmet nutritional and dietary needs and choices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #3 and Resident #46) of twelve residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #3 and #46's rooms was in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 5 (Resident #18, Resident #35, and Resident #52) residents reviewed for safe, clean, comfortable, and homelike environment. The facility failed to provide clean privacy curtains for Resident #18, Resident #35, and Resident #52. These failures could place residents at risk for an unsanitary and hazardous living conditions.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for one (Resident #12) of three residents reviewed for accuracy of assessments. The facility failed to ensure Resident #12's Quarterly MDS assessment dated [DATE] accurately reflected that Resident #12 had impairments to both upper extremities and both lower extremities. This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for two (Resident # 12 and Resident #117) of eight residents reviewed for Care Plans. 1. The facility failed to ensure Resident #12's care plan dated 02/04/2024 included a care plan for catheter care. 2. The facility failed to create a care plan for Resident #117's order for Coumadin (blood thinner.) These failures could place residents at risk for not having care plans they needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #20) of 4 residents reviewed for ADLs. The facility failed to ensure Resident #20 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infections and prevent new ulcers for 1 (Resident #50) of 4 residents reviewed for pressure ulcers . The facility WCN failed to perform hand hygiene or change her gloves after cleaning Resident #50's wounds. This failure could expose the residents to high risk of cross contamination, infection, worsening of wound conditions and serious illness.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, unless the resident's clinical condition demonstrated that this was not possible, for one (Resident #51) of five residents reviewed for nutritional status and weight loss. The facility failed to obtain Resident #51's weight per physician order. This failure could place residents at increased risk of decline in nutritional status, weight loss, and overall health and wellness.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure that two (Resident #3 and Resident #46) of ten residents were provided medications and/or biologicals and pharmaceutical services to meet the needs of the residents. The facility failed to ensure MA B re-ordered medications in a timely manner for Resident #3 (Eliquis 2.5 mg) and Resident #46 (Gabapentin 300 mg). This failure placed the residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident's medical record was kept in accordance with accepted professional standards and practices, including complete and accurately documented for one (Residnet #51) of five residents reviewed for medical records. The facility failed to ensure Resident #51's electronic medical record contained accurately documented information. This failure could place residents at increased risk of decline in overall health and wellness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure the Iced Tea Dispenser, located in the facility's only kitchen, had the cover placed on top after filing it with tea. This failure could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents with a safe, clean, comfortable, and homelike environment for 1 of 1 rooms (room [ROOM NUMBER]) reviewed for environment. The facility failed to ensure residents in room [ROOM NUMBER] were provided with a safe, clean, comfortable, and homelike environment during observations on 03/13/2023 and 03/14/2023. These failures could place residents at risk of not residing in a safe, clean, comfortable, and homelike environment. Findings Included: During observation on 03/14/2023 at 11:13am of #404, the room appeared decorated with personal items, but with various areas of scratched, chipped, and discolored/stained off-white, light brown areas to the walls. The areas of concern were as follows: 1. The wall area separating the bathroom from the resident living area had a crack approximately 2.5 feet long. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents' Care Plan was implemented for 1 of 8 residents (Resident #50) reviewed for Care Plans. The facility failed to ensure the care plan related to resident #50's Non-weight Bearing (NWB) status was implemented . This failure could place residents at risk for reinjury or further injury. Findings Included: Review of Resident #50's Face Sheet, dated 03/16/23, revealed she was a 68 -year-old female admitted on [DATE]. Relevant diagnoses included Displaced fracture of lateral malleolus of right fibula (right ankle fracture), Diabetes (high blood sugar), Pain, and difficulty walking. Review of Resident #50's MDS, dated [DATE] stated she was moderately cognitively intact with a BIMS score of 14. She required extensive assistance of one staff for bed mobility, toilet use, and personal hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #50) of 8 residents reviewed for accidents and hazards. The facility failed to ensure Resident #50 was provided with the appropriate level of assistance to support the resident during transfer to prevent her from bearing weight on her fractured ankle. This failure could place resident #50 at risk of re-injuring the ankle or falling and injuring. Findings Included: Review of Resident #50's Face Sheet, dated 03/16/23, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Displaced fracture of lateral malleolus of right fibula (right ankle fracture), Diabetes (high blood sugar), Pain, and difficulty walking. [...]