Pleasanton South Nursing And Rehabilitation

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

family member because he would get loud. The DON stated on a normal death, they should notify family, hospice, physician and facility management. She stated each hospice company was different and had their own preferences. The DON stated she was not sure what the facility policy was for family notification upon death when hospice was involved. The DON stated accurate documentation and notification were important because they wanted to make sure the family had a good death experience. She stated the facility did not have many deaths and did not have much practice. During an interview on [DATE REDACTED] at 12:03 p.m., a hospice representative stated he attended to Resident #6 as an RN but was not present on the date of her death.

He stated hospice coordinated care with the nursing facility. He stated the facility nurse would contact hospice at the time of death. He stated the hospice company would then offer to send a nurse to assist with

the death details. He stated the hospice company would never tell a facility not to notify next of kin. He stated he considered it callous not to notify family immediately. The hospice representative stated he was aware of some dynamics between the family and the facility but was not aware of any directives from hospice not to notify next of kin. Record review of the facilities policy titled Notification of Changes, last revised [DATE REDACTED], revealed: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification included: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. clinical complications 4. a transfer or discharge of the resident from the facility. Record review of the facility's policy titled Coordination of Hospice Services, last revised [DATE REDACTED], revealed, 10. The facility will immediately contact and communicate with the hospice staff, attending physician/practitioner and the family resident representative regarding any significant changes in the resident's status, clinical complications or emergent situations.

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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

11/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pleasanton South Nursing and Rehabilitation

905 West Oaklawn Rd Pleasanton, TX 78064

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 - Some

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

she could not believe she failed to document the events. She stated she did not know what happened. She stated she did not save the note. She stated she messed up. RN C stated she should have documented it directly into the progress notes. She stated she was aware the facility policy required documentation of events of the death. She stated it was important to document, so the resident's medical records were accurate. During an interview on [DATE REDACTED] at 5:15 p.m., the DON stated staff were expected to document family, hospice and other notifications. She stated the staff should clean and make the resident presentable so the family could spend time with them. She stated the staff should document the decline and the expiration. They should document vital signs that were assessed, and if appropriate, contact hospice or palliate care or the physician. She stated they should document how they find the resident, notification of local police, whether the JP responded and pronouncement of death. The DON stated this documentation was important because it painted the picture of what occurred so anyone could easily review the medical

record and see what occurred. The DON stated the facility did not experience a lot of deaths and she was aware the facility was lacking in documentation. Record review of the facility's policy titled Documentation in Medical Record, last revised [DATE REDACTED], revealed: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 1. Licensed staff and the interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

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