Park Place Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for five of ten residents (Resident #1, Resident #34, Resident #42, Resident #51, and Resident #72) reviewed for ADLs. The facility failed to ensure Resident #1, Resident #34, Resident #42, Resident #51, and Resident #72 fingernails were trimmed and maintained. This failure could place residents at risk of not receiving care services, diminished quality of life, and decreased self-esteem.1. [...]

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 for one of one kitchen reviewed for sanitation. The facility failed to date all items after they were opened. The facility failed to properly label and date all items in the refrigerator. The facility failed to ensure all items in the dry storage room were properly sealed after being opened. The facility failed to maintain clean cooking equipment. The facility failed to keep the garbage can closed when not in use. These failures could place residents at risk for foodborne illness. Observations of the walk-in refrigerator and interview from 03/03/2026, 9:18 AM - 9:40 AM revealed the following: *9:18 AM, the walk-in fridge contained an opened bottle of Italian dressing dated 2/25/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident has the right to secure and confidential personal and clinical records for 1 (Resident #92) out of 20 residents reviewed for confidentiality. LVN D left the 400-hall charting computer's screen unlocked with personal medical information of Resident #92 displayed. This failure could result in residents' personal medical information being exposed to unauthorized individuals. Observation on 03/03/2026 at 9:22 a.m. revealed that the charting computer's screen on 400 Hall nursing station was open with Resident #92's personal information displayed and visible to unauthorized individuals, including visitors or other residents not present at that time. The nurse for 400 Hall, LVN D, was not present at the nursing station. She came 5 minutes later to turn the computer screen off. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of accurate reconciliation and determine that drug records were in order, and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 5 medication carts (400-hall med cart) in the facility affecting 1 resident (Resident # 50) reviewed for pharmacy services. The facility failed to ensure CMA C accurately reconciled Resident #50's narcotic medication log when she administered but did not sign for Resident #50's Lorazepam 0.5mg three tablets. These failures could place residents at risk for loss of prescribed medications, potential for not receiving their prescribed medications, and risk of drug diversion. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs for 2 of 8 (Resident #72 and Resident #11) residents reviewed for texture-modified diets. The facility failed to serve ground ribs to Resident #72 and Resident #11 who required ground meat. This failure could place residents at risk for choking, reduced intake, and weight loss. 1. A record review of Resident #72's face sheet dated 3/05/2026 reflected a [AGE] year old male admitted on [DATE] with diagnoses of cognitive communication deficit (difficulty communicating), weakness, dysphagia (difficulty swallowing), and need for assistance with personal care. A record review of Resident #72's MDS assessment dated [DATE] reflected that he had a BIMS score of 14, which indicated he had minimally impaired cognition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's mental and psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications), and need to alter treatment significantly for one (Resident #1) of eight residents reviewed for notification of changes. The facility failed to ensure LVN A notified the doctor, nurse practitioner, director of nursing and family when Resident #1 fell on [DATE]. The facility failed to ensure LVN C notified the doctor, nurse practitioner, director of nursing and family immediately when Resident #1 appeared withdrawn and had changes in behavior. An Immediate Jeopardy (IJ) was identified on 01/08/2026. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents' environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 was monitored after a fall on 12/07/2025 which resulted in a subsequent fall on 12/13/2026 and femur fracture. The facility failed to ensure new interventions were put into place after Resident #1's 12/07/2025 fall was reported to the DON on 12/12/2025 to prevent a second fall on 12/13/2025. The facility failed to ensure new interventions were not delayed and put into place immediately after Resident #1's fall on 12/13/2025. An Immediate Jeopardy (IJ) was identified on 01/08/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accidents and supervision. The facility failed to supervise Resident #1 when she exited the facility through a door at the end of a hallway, walked down eight steps, across the parking lot and two traffic lanes then on to the center median of the road on 09/01/25. The speed limit on the road was 40 MPH. The noncompliance was identified as PNC (Past non-compliance). The IJ (Immediate Jeopardy) began on 09/01/25 and ended on 09/03/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of injuries and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to be free from misappropriation of resident property for one of one controlled medication storage cabinet reviewed for misappropriation. The facility failed to prevent the misappropriation of an unknown number of controlled medications being stored for destruction. The medications and the Drug Destruction Log were discovered missing on 09/30/25. This failure could place residents at risk of misappropriation of property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from psychosocial abuse and neglect for five (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) of ten residents reviewed for abuse and neglect. The facility failed to:Ensure Resident #1 was free from verbal and emotional abuse by NA A on or around 05/30/25 and they failed to immediately suspend NA A (per their policy) as she had worked at the facility (26 shifts) since the incident. The facility did not investigate/report the incident because the DON stated Resident #1 later denied the allegation. Conduct thorough abuse/neglect investigations as they (staff) were photo-copying Abuse and Neglect in-services and changing the date without in servicing the staff for four separate self-reports, dated 06/14/25, 06/22/25, 06/26/25, and 07/02/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and establish policies and procedures to investigate any such allegations for one (Resident #1) of ten residents reviewed for abuse and neglect. The facility failed to: - Follow their Abuse and Neglect policy after Resident #1 was verbally/emotionally abused by NA A on or around 05/30/25 by not investigating the incident, not suspending NA A, and not reporting it to the ADM which resulted in psychosocial harm for Resident #1. An Immediate Jeopardy (IJ) was identified on 07/09/25 at 3:24 PM and an IJ template was provided. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made for one (Resident #1) of ten residents reviewed for abuse. The facility failed to: - Ensure Resident #1 was free from verbal and emotional abuse by NA A on or around 05/30/25 and they failed to immediately suspend NA A (per their policy) as she had worked at the facility (26 shifts) since the incident. The facility did not investigate/report (to HHSC) the incident because the DON stated Resident #1 later denied the allegation. - Notify the Abuse and Neglect Coordinator (ADM) of the alleged abuse by NA A towards Resident #1 so it could be investigated and handled appropriately to ensure her safety. [...]

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure in response to allegations of abuse, neglect, or mistreatment, have evidence that all alleged violations were thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for two of ten (Resident #6 and Resident #7) residents reviewed for Abuse and Neglect. The facility failed to thoroughly investigate and report within 5 working days, when Resident #6 reported her roommate, Resident #7, hit her and twisted her arm on 06/14/25. The Provider Investigation Report was due on 06/19/25 but was not submitted until 07/09/25 This failure could place residents at risk for abuse, neglect, and exploitation.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 4 (400) halls observed for housekeeping and maintenance services. The facility failed to ensure there were not a black circular substance under the wallpaper in three residents (Resident #1, Resident #2, and Resident #3) rooms. This deficient practice could place residents at risk of living in an unclean and unsanitary environment and result in potential health issues or affecting the airway.

Inspectors wroteBased on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the state survey agency within five working days of the incident for two (2) of five (5) residents reviewed for abuse and neglect. (Resident #2 and Resident #4). The facility failed to thoroughly investigate two facility reported incidents regarding Resident #2 and Resident #4 within five (5) days regarding allegations of neglect and injury of unknown origin. This deficient practice placed all residents at risk of harm form neglect due to not having a thorough investigation done for facility reported incidents. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative(s) of the discharge and the reasons for the discharge in writing and in a language and manner they understand for 1 of 5 residents reviewed for discharge notification. (Resident #1) The facility did not give a written notice of discharge, when Resident #1 was transferred into Police custody on 02/19/2025. This failure could affect residents by placing them at risk of being transferred and not having access to available advocacy services, discharge/transfer options, and appeal processes.

Inspectors wroteBased on, interview, and record review the facility failed to ensure residents were free from neglect for 1 of 4 residents (Resident #1) reviewed for abuse and neglect. CNA A and LVN B failed to check on Resident #1 on the night of 01/09/2025 from about 10:00 pm through the morning of 01/10/2025 at about 4:40 am, leaving Resident # 1 unattended for about 6 hours. Resident #1 fell on the floor and was on the floor the entire night unattended by staff. When Resident #1 was found on the morning of 01/10/2025, he was noted with abrasion at his left arm, combative, angry and speaking Spanish. The noncompliance was identified as PNC. The IJ began on 01/09/2025 and ended on 01/17/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of Neglect, injury, and psychosocial harm.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 2 (Resident #1 and Resident #2) of 2 residents reviewed for intravenous care. The facility failed to ensure Resident #1 had orders to change her PICC line dressing after the PICC was placed. She went from 12/18/24 until 01/09/25 without a PICC dressing change. The facility failed to ensure the ADON changed Resident #1's PICC line dressing per the facility protocol. The facility failed to ensure Resident #1 had orders to flush the PICC or to monitor the PICC insertion site for signs/symptoms of infection from 12/18/24 through 01/09/25. The facility failed to ensure Resident #2 had orders to flush the PICC or to monitor the PICC insertion site for signs/symptoms of infection from 11/13/24 through 11/27/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nurses were able to demonstrate the specific competencies and skill sets necessary to care for the resident's needs for 1 (Resident #1) of 1 resident provided care by 6 of 6 nurses (ADON, RN A, LVN B, LVN C, LVN D, and LVN E) reviewed nursing competency. The facility failed to ensure the ADON, RN A, LVN B, LVN C, LVN D, and LVN E who provided central line care and maintenance to Resident #1 from 12/18/24 through 01/09/25 were knowledgeable and competent on the facility's central line policy. These failures could place residents with central lines at risk of infection, line malfunction, hospitalization, and not receiving medication as ordered.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices was occurring including cleaning the ice machine, cleaning the microwave, cleaning the meat slicer and utilizing a meat slicer that had a rusty slicing blade, having trash receptacles without lids secured, having ingredient bins with scoops in them, utilizing a ice scoop holding receptacle with no lid and that had dirt and debris in the bottom touching the ice scoop, cleaning the juice gun nozzle, and proper hair restraints. 2. The facility failed to label and date all food items in the kitchen. 3. The facility failed to have hand wash sinks that did not leak. 4. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 5 of 11 residents (Resident #40, Resident #3, Resident #18, Resident #25, and Resident #253) reviewed for infection control. 1. LVN B did not label wound care dressings, per facility stated policy, for Resident #40, Resident #18, Resident #3, and Resident #25. 2. LVN B did not place a barrier, between the resident's body part and the bedding, prior to Resident #40's wound care and rested Resident #40's foot on the blanket. 3. LVN N provided catheter care to Resident #253 with without wearing EBP. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had the right to receive services with reasonable accommodation of resident needs and preferences for 1 of 11 residents (Resident #88) reviewed for accommodation of needs. The facility failed to ensure Resident #88's call light bell was within arm's reach. This failure could place residents at risk for low quality care and psychosocial harm.

Inspectors wroteBased on interview and record review the facility failed to manage the personal funds of the resident deposited with the facility for 1 (Resident #25) of 5 residents reviewed for trust funds. The facility failed to ensure Resident #25 had ready access to her personal funds upon request in a timely manner. This failure could place all residents whose funds are managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored. Findings Included: Record review of Resident # 25 admission face sheet dated 12/12/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] and then readmitted on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that the residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the residents through the means other than a postal service for 2 (Resident #14 and Resident #253) of 11 residents in a group meeting reviewed for resident rights. The facility failed to ensure Residents #14 and #253 received packages unopened. This failure could affect residents by placing them at risk of not receiving packages unopened that could result in residents experiencing diminished psychosocial well-being and quality of life.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment reviewed for care plans for 1 of 4 (Resident #47) reviewed for daily activities. The facility failed to ensure Resident # 47's care plan addressed daily activities. This failure placed residents at risk of social isolation and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #66) of 3 residents reviewed for quality of care. The facility failed to ensure repairs was made to Resident #66's custom wheelchair in a timely manner. This failure could place residents at risk of not receiving care to maintain optimum health and placing them at risk for decline in health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents that required respiratory care were provided such care consistent with professional standards of practice, person-centered care plan, and resident's goals and preferences for 1 of 2 residents (Resident #253) reviewed for respiratory care. The facility failed to maintain Resident #253's BIPAP (Bilevel Positive Airway Pressure) machine in an unusable condition. This failure could place residents at risk of complications from respiratory distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #3) of three residents reviewed for quality of care. The facility failed to schedule an appointment in a timely manner with a neurologist as ordered by Resident #3's cardiologist. This failure could place residents at risk of not receiving necessary medical care, harm, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3 residents (Residents #3 ) reviewed for quality of care. The facility failed to implement Resident #3's Care Plan which included the use of a CPAP for sleep apnea. This failure could place residents at risk of not receiving necessary medical care, a decrease quality of sleep and cardiovascular impairments.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 1 facility reviewed for safe, clean, and comfortable environment. The facility failed to replace the countertop over a set of cabinets, for about a year, when remodeling in the dining room. This failure could place residents at risk for uncomfortable, unhomelike environment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #2) of five residents reviewed for changes in condition. The facility failed to notify Resident #2's RP of a metacarpal fracture until ten days after receiving the results of the x-ray. This failure could put residents at risk of not having their care needs and health changes communicated and addressed with their responsible party.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Resident #1) of five residents reviewed for unnecessary medications. The facility failed to ensure Resident #1 had a preexisting mental illness for which an antipsychotic medication (Zyprexa) would be warranted. This failure could place residents at risk for unnecessary psychotropic drug use.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents/resident representatives were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment, and treatment alternatives or treatment options, and to choose the alternative or option he or she prefers for one (Resident #1) of three residents reviewed for consents. The facility failed to obtain a written consent from Residents #1's Representative (RP) before administering her Xanax (a medicine used to treat the symptoms of anxiety). This failure could place residents at risk of not having their preferred responsible party represent them in medical and care decisions.

Inspectors wroteBased on interviews and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for one (Resident #1) of three residents reviewed for pharmacy services. The facility failed to ensure Resident #1 had a stop date for PRN Xanax (a medicine used to treat the symptoms of anxiety). This failure could place residents at risk of being overmedicated or receiving unnecessary medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent falls and injury for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to safely perform a one-person transfer and prevent fall and injury for Resident #1, which resulted in Resident #1 falling straight forward and landing on his forehead and sustaining an 8-centimeter large forehead laceration and an acute compression fracture of T-3 vertebra. EMS was activated, and Resident #1 was hospitalized from [DATE] - 11/10/23. This failure could place residents at risk of not receiving the care and services to meet their needs and services to prevent serious harm, serious impairment, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 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 three of nine residents (Residents #6, 45, and 67) reviewed for personal hygiene. The facility failed to provide nail care for Residents #6, #45, and #67, oral hygiene to Resident #67, and showers according to schedule for Resident #45. This failure placed residents at risk of embarrassment, dental issues, skin breakdown, and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's drug regimen was free from unnecessary drugs for 1 of 8 residents (Resident #21) reviewed for unnecessary drugs. The facility failed to monitor Resident #21 for adverse effects of prophylactic antibiotic use. This failure placed residents at risk of nausea, diarrhea, and secondary infection.