Denton Village By Purehealth

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

and call family to assist. She stated Metformin was in their E-kit and on the outside of the E-kit, there was a list of what medications were in it. She stated if the medication was not in the E-kit she would get the medication from the pharmacy. She stated if a resident had a 600 BS level, she would first check to see if

they had sliding scale insulin and if they did not she would call the doctor to get a doctor's order for a treatment. She stated she would of course assess the residents and monitor them and keep calling the doctor over and over again until the doctor was reached. She stated for a hospice resident she would follow

the doctor's orders and if they did not have a sliding scale she would call hospice first and for no response

she would call the resident's facility doctor. She stated she would notify the FM/RP about the 600 high BS if

the resident was on hospice and would let the FM/RP know as well to get them to help with reaching out to hospice. She stated she would document everything in the resident's progress note for their attempts with whom she contacted at the hospice provider. She stated she would document why they were being contacted and who she spoke to and what the response was from the on-call office and hospice nurse. She stated once the hospice provider gave orders to treat she would document what the hospice provider said and made sure the orders were added to the orders for the next nurses to follow. She stated she would then follow through on the treatment plan and notify the next nurse what happened. She stated if there BS did not decrease it would be considered emergent, and she would call 911 and would definitely send the resident to the hospital then call the FM/RP and doctor or hospice provider. She stated if the resident did not get a treatment, they could go into diabetic ketoacidosis or a coma. She stated if a resident did not have medication she would document in the progress note and in the 24-hour report book and said if she noticed something needed to be taken care of that same day she would let the DON know about the situation. She stated she would follow the resident's sliding scale orders and administer the insulin needed for that BS level and would recheck their BS level a few minutes after giving it. She stated she would let the hospice nurse know about the 600 BS level and asked what did they need to do about it like giving a fast acting or smaller dose of insulin for example then rechecking the BS level 30 minutes later. She stated before sending a resident out she would do an assessment and check the resident's vitals including the BS and if

they had a seizure she would review to

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Denton Village by Purehealth

2500 Hinkle Dr Denton, TX 76201

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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

ensuring the residents' records were accurate and complete, but the MDS Coordinator was responsible for ensuring the MDS assessments were accurate. He stated the DON reinforced that leadership had all the information for the residents and to report any issues that they needed to address. He stated he did not want to say what could happen to a resident if their medical records were not accurate and complete.

Interview on 11/18/25 at 5:07 pm, the DON stated the MDS Coordinator was responsible for ensuring all

the residents' diagnoses were on their MDS Assessments. He stated he was not sure how that was missed and said not having all of the residents' diagnoses could cause a resident to get improper care or lack of care, which could run into several complications as the end result. Interview on 11/18/25 at 5:46 pm, the Administrator stated she was not sure why Resident #1's diagnoses were not on his MDS Assessment because she was not a nurse to have been able to say that was missing. She stated the clinical leadership team was responsible for the accuracy of the residents' records and the hospice provider was responsible with ensuring they gave them accurate information. She stated the IDT was responsible for ensuring the resident's records were accurate. She stated she did not know how to answer the question on how it could affect the residents if their medical records were not accurate and correct, but they had a protocol they went by.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Denton Village by Purehealth

2500 Hinkle Dr Denton, TX 76201

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Care Plans were inaccurate. He stated his role was to review the residents' documentation that reflected what the staff were documenting. He stated the IDT was responsible for reviewing and ensuring the residents' records were accurate and complete, He stated the DON reinforced that leadership had all the information for the residents and to report any issues that they needed to address. He stated he did not want to say what could happen to a resident if their medical records were not accurate and complete.

Interview on 11/18/25 at 5:07 pm, the DON stated the MDS Coordinator was responsible for ensuring all

the residents' diagnoses were on their face sheets. He stated he was not sure how that was missed and said not having all of the residents' diagnoses could cause a resident to get improper care or lack of care, which could run into several complications as the end result. Interview on 11/18/25 at 5:46 pm, the Administrator stated she was not sure why Resident #1's diagnoses were not on his face sheet and care plan because she was not a nurse to have been able to say that was missing. She stated the clinical leadership team was responsible for the accuracy of the residents' records and the hospice provider was responsible with ensuring they gave them accurate information. She stated the IDT was responsible for ensuring the resident's records were accurate. She stated she did not know how to answer the question on how it could affect the residents if their medical records were not accurate and correct, but they had a protocol they went by. On 11/18/25 at 5:35 pm the facility's medical record policy was requested and the Administrator stated she would provide it. On 11/19/25 at 2:18 pm the Administrator stated they did not have a one.

Event ID:

Facility ID:

If continuation sheet