Mustang Park Therapy and Living Center

In the surveyor’s words

From the most serious findings on record at Mustang Park Therapy and Living Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 16, 2025

  Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #6) reviewed for accidents and hazards. The facility failed to ensure Resident #6 did not exit the facility through an unknown door and walk 2.7 miles to a free-standing emergency department where he was found outside. The noncompliance was identified as PNC. The noncompliance began on 03/13/2025 and ended 03/14/2025. […]

• Immediate jeopardy, isolatedF689Aug 9, 2021

  Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #58) of four residents reviewed for elopements. 1. The facility failed to ensure Resident #58 was adequately supervised to prevent the resident from leaving the facility unsupervised. Resident #58 had severe cognitive impairment, wandering behavior, was a high fall risk and lacked safety awareness. Resident #58 eloped from the facility on 08/03/21 and was found by facility staff in the grass 12 feet from the facility in the back-parking lot area. 2. The facility failed to ensure staff were trained and able to demonstrate competency on elopement and supervision. An Immediate Jeopardy was identified on 08/06/21 at 2:00 p.m. […]

• Actual harm, isolatedF580Mar 1, 2024

  Based on interviews and record review, the facility failed to notify and consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status for 1 (Resident #1) of 5 residents reviewed for Notification of Changes. 1. The facility failed to notify the wound physician on 01/11/24 about an open area discovered on Resident #1's sacrum. The area developed into an unstageable pressure ulcer (PU) (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present) to the sacrum. The WMD assessed and evaluated the sacrum wound on 01/23/24. […]

• Actual harm, isolatedF686Mar 1, 2024

  Based on interviews, observations, and record reviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote the prevention of pressure ulcer/injury development, the healing of existing pressure ulcers/injuries, and prevent development of additional pressure ulcer/injury for 1 (Resident #1) of 5 residents reviewed for quality of care, in that: 1. The facility failed to consistently perform weekly skin assessments for Resident #1. 2. On 01/11/24, LVN C notified the primary physician of a dime-sized open area to Resident #1's sacrum. The facility implemented the interventions/treatment to the open area but failed to consult the WMD (for 12 days, 01/11/24 - 01/23/24) as ordered. 3. […]

• No harm, potential for more than minimal, widespreadF851Jan 8, 2025

  Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS fiscal year 2024 for the second quarter (January 1, 2024, to March 31, 2024) reviewed for Administration. The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for January 1, 2024, to March 31, 2024. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. […]