Park Manor of the Woodlands

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review on a daily basis at the beginning of each shift for 1 of 1 facility reviewed for required postings. The facility failed to update the daily nursing postings on 02/05/26. This failure could affect residents, by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: An observation on 02/05/26 at 09:08 AM revealed, the facility Daily Nursing Staff Direct Responsible for Resident Care on the top of the center nursing station facing the front door that read 02/04/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety reviewed for food procurement in 1 of 1 kitchen to demonstrate the prevalence of the noncompliance in that: -The facility failed to ensure 10 pounds of raw fish was stored at proper temperature. -The facility failed to ensure scoops were not stored in food bins. -The facility failed to ensure gallons of milk were not stored on a rack 4 1/2 inches off the floor. These failures could place residents at risk of food borne illnesses and diseases. Observation and interview on 9/09/25 between 8:30 am and 8:40 am with the Dietary Manager revealed the following: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish and 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 3 of 3 residents (Resident #75, Resident #78 and Resident #79) and 1 of 1 Kitchen (Kitchen A) reviewed for infection control. 1. The facility failed to ensure MA E used the required PPE for Resident #75, who was on enhanced barrier precautions, while checking BP on 9/23 /25. 2. The facility failed to ensure LVN K used the required PPE for Resident #78 on 9/23/25. 3. The facility failed to ensure CNA B maintained hand hygiene during incontinent/FC on 9/24/25 for Resident #79. 4. The facility failed to ensure CNA B cleansed around the buttocks for Resident #79 on 9/24/2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (Resident #79) reviewed for ADL care. The facility failed to ensure CNA B cleaned Resident #79 properly during incontinent care on 9/24/25. This failure could place residents at risk for pain, infection and hospitalization. Record review of Resident #79's face sheet reflected the date of admission was 8/27/25 and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #79) reviewed for incontinent care. 1. The facility failed to ensure CNA B properly cleaned Resident #79's indwelling Foley catheter.2. The facility failed to ensure CNA B followed proper hand hygiene during incontinent care on 9/24/25.3. The facility failed to ensure CNA A secured Resident #79's Foley catheter. These failures could place residents at risk for pain, infection, injury, and hospitalization. Record review of Resident #79's face sheet reflected the date of admission was 8/27/25 and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and prevent complications of enteral feedings including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #78) reviewed for feeding tubes. The facility staff failed to ensure LVN K verified placement of Resident #78's feeding tube prior to medication administration on 9/23/25. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records on each resident were maintained that were complete and accurately documented for 1 of 6 residents (Resident #144) reviewed for accurate records.-The facility failed to ensure urine output was documented on 9/14/2025 and 9/19/2025 per physician orders for Resident #144. This failure could place residents at risk of changes in condition not being detected and treated in a timely manner. Record review of Resident #144's face sheet, dated 09/25/2025, reflected a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 16% based on 4 errors out of 25 opportunities, which involved 1 of 8 residents (Resident #99) reviewed for medication errors. -The facility failed to ensure LVN N administered the correct dose of Potassium Chloride or Ferrous sulfate liquid to Resident #99 according to Physician orders. -The facility failed to ensure LVN N did not crush and administer; Acetaminophen ER (an extended-release formulation which should not be crushed) to Resident #99 via g-tube (a way to deliver liquid nutrition through a flexible tube to your digestive system) instead of Acetaminophen as ordered by the Physician. These failures could place residents at risk of inadequate therapeutic outcomes.

Inspectors wroteBased on interview and observation the facility failed to ensure residents received drinks consistent with preference and sufficient to maintain hydration for 10 of 10 (confidential group) and 3 of 21 (Resident #1, Resident #2, and Resident # 78) of residents reviewed for hydration. The facility did not provide hot coffee to residents during mealtimes. This failure could place residents who depend on the facility for their hydration needs at risk for thirst, dehydration, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in 1. The facility failed to ensure that ice scoops will be cleaned and stored in a separate container that limits cross-contamination. 2. The facility failed to ensure that all cold and dry goods items will be stored 6 inches above the floor. These failures could place residents at risk of foodborne illness and disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement person-centered care plans for each resident's services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 21 residents (Resident #86) reviewed for the develop and implement comprehensive care plans. - The facility failed to ensure Resident #86's comprehensive care plan included the care for her schizoaffective and delusional diagnoses. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.