Park Village Healthcare and Rehabilitation

Inspectors wroteBased 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 for 1 (CMS for FY Quarter 1 2026) of 4 quarters reviewed for compliance. The facility failed to submit accurate staffing information to CMS for FY Quarter 1 2026 (October 1-December 31). This failure could place 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to facility properly labeled and stored all drugs and biological in accordance with currently accepted professional principles for medications on 3(300 hall, 100 South Hall, and 100 North Hall) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure Zofran 4 mg prescription medication used to prevent and treat nausea and vomiting was labeled with patients' labels on the 100-south hall -medication cart. The facility failed to ensure Linezolid 600mg prescription antibiotic primarily used to treat bacterial infections was labeled with patients' labels on the 100-south hall -medication cart. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 5 residents (Resident #10) reviewed for PASRR Level I screenings. The facility did not correctly identify Resident #10 as having a mental illness and did not complete a new PASRR Level I Screening. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #98) of five residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #98 within 48 hours of her admission. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 2 Residents (Resident# 103 and Resident# 8) of 6 Residents reviewed for pharmacy services. The facility failed to ensure proper storage and disposal of Resident #103's Tramadol HCL tab 50mg- (controlled medication) by taping a narcotic medication and storing it in the medication cart. The facility failed to ensure properly disposal of Resident #8's hydrocodone 5-325mg (controlled medication) which expired on [DATE]. These failures could place residents at risk of drug diversion, medication error, and risk of pills contamination due to broken seals.

Inspectors wroteBased on interview and record review, the facility failed to establish and implement smoking safety policies and procedures for 1 (Resident #59) of 6 residents reviewed for smoking safety. The facility failed to complete an initial smoking assessment for Resident #59 to determine the resident's ability to smoke safely, need for supervision, and appropriate smoking interventions in accordance with facility smoking policies. This failure placed residents at risk for smoking related accidents, burns, and other safety hazards.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 6 residents (Resident #1) reviewed for assessments: The facility failed to ensure Resident #1's quarterly MDS assessment, dated 09/23/25, included the behavior of wandering in Section E of the assessment. These failures could place residents at risk for inadequate care.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #1) of 6 residents, reviewed for care plans. The facility failed to ensure a care plan was developed to address Resident #1's wandering behavior and note interventions prior to 09/30/25. This failure could place resideFindings Include:Record review of Resident #1's face sheet, dated 10/07/25, reflected an [AGE] year-old male, who admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure, in accordance with professional standards and practices, medical records were maintained on each resident that that were complete and accurately documented for 1 of 6 resident records (Resident #1) reviewed for treatment documentation. The facility failed to document Resident #1's routine wandering since his admission on [DATE] and his increased wandering about 2-4 weeks before 09/30/25. The facility failed to ensure 8 of Resident #1's Elopement Wandering Assessments, did not note an incorrect diagnosis of Dementia. This failure could place residents at risk of medical records not being an accurate representation of medical condition or medical needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from abuse and neglect for 2 of 8 residents (Resident #1 and Resident #2) reviewed for abuse and neglect. The facility failed to ensure there was no inappropriate sexual behavior between Resident #1 and Resident #2. Resident #1 was observed in the dining room by CNA-A massaging the breast of Resident #2. An Immediate Jeopardy (IJ) was identified on 11/14/25. The IJ template was provided to the facility on [DATE] at 7:12 PM. While the IJ was removed on 11/15/25, the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained. This failure placed other female residents at risk and or potential risk of abuse/neglect Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 2 of 18 residents (Resident #1, Resident #2) reviewed for abuse and neglect. The facility failed to thoroughly investigate inappropriate sexual behavior between Resident #1 and Resident #2. Resident #1 was observed in the dining room by CNA-A massaging the breast of Resident #2. An Immediate Jeopardy (IJ) was identified on 11/14/25. The IJ template was provided to the facility on [DATE] at 7:12 PM. While the IJ was removed on 11/15/25, the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 8 residents (Resident #2) reviewed had a change of condition. The facility staff failed to notify the designated representative and the NP of Resident #2 that she had been sexually abused by Resident #1. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours after the allegation was made, if the events that caused the allegation involve abuse to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for 2 of 8 residents (Resident #1 and Resident #2) reviewed for abuse and neglect. The facility did not make a report to local law enforcement or State Survey Agency (HHS) of an allegation on 11/05/25 when Resident #1 was found in the dining room massaging the breast of Resident #2 after he had taken off her adult brief. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 (Resident #2) of 5 residents reviewed for abuse. The facility failed to ensure Resident #2 was free from abuse when Resident #1 punched him on 09/09/25, causing Resident #2 to have a scratch on his nose. This failure could place residents at risk for severe and long-lasting impacts on physical, psychological, and emotional wellbeing.

Inspectors wroteBased on observations, interviews, and record reviews, 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 two (Resident #1 and Resident #2) of five residents, reviewed for infection control. 1. The facility failed to ensure LVN A wore the appropriate PPE and performed hand hygiene during wound care for Resident #1. 2. The facility failed to ensure CNA C and CNA D performed hand hygiene during incontinence care for Resident #2. This failure placed residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 (Resident #1's room) of 8 residents room reviewed for pest. The facility failed to ensure Resident #1's room was free of ants on 07/20/25. As a result of the bites Resident#1 was transported to the local hospital and admitted on [DATE]. Based on observation, record review and interview, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 (Resident #1's room) of 8 residents room reviewed for pest. The facility failed to ensure Resident #1's room was free of ants on 07/20/25. As a result of the bites Resident#1 was transported to the local hospital and admitted on [DATE]. The non-compliance was identified as past non-compliance (PNC). [...]

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 1 of 1 kitchen reviewed for kitchen safety. 1. The cook failed to sanitize the thermometer between checking breakfast food on 06/20/25. 2. The cook failed to check the temperature of the cinnamon rolls, biscuits and fried eggs before they were served to the residents, These deficient practices could affect residents who received meals and/or snacks from the facility's only kitchen by placing them at risk for cross contamination and other food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 (Halls 100 and 400) of 3 halls reviewed for environmental concerns. 1. The facility failed to lock 2 Hoyer lifts , bed with mattress, bed frame in the hallway on 06/19/25 could be a fall risk and injury concern and issue for residents. 2. The facility failed to lock 1 Hoyer lift, bed frame and left pallet seating upright by the storage supply closet on 06/20/25 could be a fall risk and injury concern and issue for residents. This deficient practice could place residents at risk of falls, injuries, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Hall 400) of three medication carts reviewed for pharmacy services. On 06/19/25, LVN A failed to ensure medication cart was locked when not being used at the nursing station on Hall 400. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to file grievances anonymously for 1 (Resident #1) of 3 residents reviewed for grievances. 1. The facility failed to ensure Resident #1 had access to file a grievance anonymously. The facility's failure could place the residents at risk for concerns not being reported and addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the transmission of disease and infection; maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors; follow accepted national standards; follow a system of surveillance designed to identify possible communicable diseases or infections before they could spread to other persons in the facility; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #14, Resident #64, Resident #69) of 6 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #14 had his fingernails trimmed on 03/18/25. 2- Resident #64 had her fingernails cleaned and trimmed on 03/19/25. 3- Resident #69 had her fingernails cleaned and trimmed on 03/19/25. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 8 residents (Residents #36) reviewed for dental services. The facility failed to provide timely dental services for Resident #36 when he started having tooth pain on 02/11/25. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior environment for one residents' room (room [ROOM NUMBER] 301 ) of 6 residents' rooms reviewed for clean and sanitary environment. The shared bathroom in resident room [ROOM NUMBER] 301 had a water leak coming from underneath the toilet seat crossing in front of the sink and going to the shower drain. These failures could affect residents by placing them at risk of not having a clean, sanitary, and comfortable environment.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents right to be free from physical abuse by Resident #60 for 1 resident (Resident #6) of 24 residents reviewed for abuse and neglect. On 01/25/25, Resident # 60 swung at Resident #6 and hit Resident # 6's right eye. Resident # 6 sustained bruising under the right eye. This failure placed the facility's residents at risk for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to immediately report an alleged act of abuse to the State Survey Agency, for 2 residents (Resident #6 and 60) of 24 residents reviewed for abuse and neglect. The facility failed to immediately report an allegation of physical abuse. This failure placed the facility's residents at risk for abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing and administering, of medications for 2 (Nursing Medication cart hall 100 North and nursing medication cart 300 hall) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure prompt identification of potential diversion of controlled medications when CMA B did not report a damaged blister pack of Clobazam 20 mg (controlled medication) and LVN D C did not report a damaged blister pack of Tylenol with Codeine#4 oral tablet 300-60 mg (controlled medication). This failure could place residents at risk of not having their medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication.

Inspectors wroteBased on observation, and interview the facility failed to ensure the call system was within reach of the resident, and accessible to a resident lying on the floor for 2 Residents' rooms bathroom (room [ROOM NUMBER] 302, room [ROOM NUMBER] 303) of 6 residents' rooms bathrooms reviewed for residents' call systems. - The facility failed to ensure the call light system was accessible to a resident lying on the floor in the residents' toilets located in the secured unit room [ROOM NUMBER] 302 - The facility failed to ensure the call light system string was not missing, and was accessible to a resident, including a resident lying on the floor in the residents' toilets located in the secured unit room [ROOM NUMBER] 303 This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident has the right to reside and receive services in the facility with accommodation of resident needs and preferences for one (Resident #1) of five residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system was within reach of the Resident #1 lying in bed. This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #1) of one resident reviewed for catheter care. The facility failed to ensure Resident #1's urine catheter drainage bag kept off the floor when Resident#1 was lying in bed. This failure could place residents at risk for urinary tract infections.

Inspectors wroteBased on observations and interviews, 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 1 (Resident #2) of 5 residents reviewed for infection control LVN A failed to wear appropriate PPE when providing suprapubic catheter care for Resident #2 who supposed to be on EBP ( Enhanced Barrier Precautions). This failure placed the residents at risk of exposure to possible infectious agents.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to provide a safe environment for five (Residents #1, #2, #3, #4, #5) of 12 residents reviewed for safe environment. The facility failed to ensure Residents #1, #2, #3, #4, #5's rooms were free from black ants from 08/04/24 to 08/26/24. Theses failures could place all residents at risk for ant bites, which could cause skin infections, allergic reactions, skin tears, scratches, scarring, and rashes resulting in pain and decline in health and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for five (Residents #1, #2, #3, #4 #5) of 12 residents reviewed for incident accidents. The Nursing staff failed to ensure black ants were not in Residents #1, #2, #3, #4 and #5's rooms and beds. These failures could place residents at risk of being bitten by ants causing skin irritation, skin infection and pain resulting in decreased health and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that were accurately documented and must contain a record of the resident's assessment for five residents (Residents #1, #2, #3 #4 and #5) of 12 residents reviewed for Medical Records. The Nursing staff failed to ensure incident reports, skin assessments and Nurse progress notes were completed after reports of black ants were found in the rooms and beds of Residents #1, #2, #3, #4 and #5. These failures could affect all residents by placing them at risk of not being properly monitored and treated if documentation were not completed, accurate or missing which could result in decline in their health and psycho-social well-being.

Inspectors wroteBased on interviews, observation, and record reviews the facility failed to Maintain an effective pest control program so that the facility is free of pests in Residents #1, #2, #3, #4, and #5's rooms reviewed for pest control. The facility failed to ensure Residents #1, #2, #3, #4, and #5's rooms were free from black ants from 08/04/24 to 08/26/24. Theses failures could place all residents at risk for ant bites, which could cause skin infections, allergic reactions, skin tears, scratches, scarring, and rashes resulting in pain and decline in health and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Treatment Cart #1) of two treatment carts reviewed. The facility failed to ensure Treatment Cart #1 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide routine and emergency drugs and biologicals to its resident for one (Resident #1) of three Residents reviewed for pharmacy services MA-A failed to administer all of Resident #1's medications. This failure could place the resident at risk of not receiving the full effects intended by the physician.

Inspectors wroteBased on observations and interviews, 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 one (Resident #2) of 6 residents reviewed for infection control CNA-B and CNA-C failed to wear appropriate PPE when providing care for Resident #2 who was on EBP. This failure placed the residents at risk of exposure to possible infectious agents.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. These services are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for four resident rooms (resident #327, #73, #16 and #11) of 24 resident rooms reviewed for clean and sanitary environment. 1. Resident #327's room had two nails on the floor, a plastic cup and the floor was dirty. 2. Resident #73's room had a hole behind the door at the entrance to the room. 3. Resident #16's room had broken blinds, a stain on the wall by the bathroom, and the toilet was running causing the pipes to make a loud whining noise. 4. Resident #11's room had broken blinds and a hole behind the door at the entrance to the room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #327) of 5 residents reviewed for ADLs. The facility failed to ensure Resident #327 had her fingernails cleaned and trimmed and was provided incontinent care for more than 4 hours on 2/7/24. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's kitchen, reviewed for kitchen sanitation. The facility failed to ensure liquid Kool Aid stored in the facility's walk-in refrigerator was covered, labelled and dated. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one (Resident #57) of 6 residents reviewed for resident call system The facility failed to ensure the call light in resident room [ROOM NUMBER] used by Resident #57 for dialysis treatment went to a centralized staff work area. This failure placed resident at risk of a delay in receiving assistance from facility staff and being unable to obtain assistance in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to honor the resident right to choose his or her attending physician for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility did not honor Resident #1's right to choose his primary care physician as his attending physician. This deficient practice could place residents at risk of decreased quality care and treatment due to their lack of free choice for their attending physician care while in the facility.

Inspectors wroteBased on interview and record review, the facility failed to assist the resident in making transportation arrangements to and from the source of service, if the resident needs assistance for 1 of 3 residents (Resident #1) reviewed for transportation services, in that The facility failed to ensure Resident #1 was provided transportation to services from outside entities on 12/07/23 and 12/15/23. This failure could result in missed appointments and delayed treatments.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Medication Cart #1) of three medication carts reviewed for pharmacy services. The facility failed to ensure Medication Cart #1 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.

Inspectors wroteBased on interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of 22 residents reviewed for notification of changes. The facility failed to promptly identify and intervene for an acute change in a resident's condition related to type 2 diabetes, resulting in the family calling 911 to transport the resident to the hospital. The resident was admitted to the hospital with increased confusion, poor wound healing, hyperglycemia (elevated blood sugar levels), and septicemia (bacterial blood infection). LVN B (Agency Nurse) failed to consult with the physician or physician assistant when Resident #1's blood sugars were greater than 200 on 9/24/2023. [...]

Inspectors wroteBased on 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, as based on the comprehensive assessment of the resident; in that: The facility failed to promptly identify and intervene for complications of acute hyperglycemia (high blood sugar) for one (Resident #1) of 22 residents reviewed for hyperglycemia related to type 2 diabetes, resulting in the family calling 911 to transport the resident to the hospital. This failure could place residents at risk for delayed interventions in treatment when glucose levels spike or drop due to underlining conditions. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident/RP has the right to be informed of, and participate in, his or her treatment for one (Resident #1) of 22 residents reviewed for resident and RP rights. Resident #1's RP was not notified when the physician's order for glucose monitoring was entered as once-a-week monitoring the day after Resident #1 admitted to the facility. Prior to admitting to the facility, Resident's glucose was monitored twice daily. Resident #1's RP was not educated on the risks or benefits of testing glucose less frequently to make an informed consent to the change. The resident was hospitalized for 10 days with increased confusion, poor wound healing, hyperglycemia (high blood sugar), and septicemia (bacterial infection of the blood). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medications errors for one resident (Resident #1) of 22 residents reviewed for medication accuracy in that: The facility failed to hold antibiotic medication (Amoxicillin/Clavulanate) after orders were attached to Resident #1's hospital discharge documents until after 3 doses were administered 10/01/2023 to 10/02/2023. The facility failed to ensure Resident #1 was not administered medications that belonged to another resident that was a hospital patient. This failure could place residents at risk of receiving medications not ordered by their physician, which could cause exacerbate kidney disease, diarrhea, and nausea.

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 of 2 residents (Resident #1) reviewed for accidents. The facility failed to safely transfer Resident #1 and prevent and injury during the use of the mechanical Hoyer lift, which resulted in the resident sustaining a laceration to the head, requiring six staples at the hospital. This failure could place resident at risk for accidents, injuries, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately notify the resident's representative when there was a significant change in the physical status and consult with the resident physician for one of three residents (Resident #2) reviewed for notification of change in condition. LVN failed to notify Resident #2's resident representative of the significant change of condition of pain, notify the physician, and request for x-ray of the right knee on 10/08/23. This failure could place residents at risk for a delay in treatment and not receiving proper care due to failure to notify resident representative.

Inspectors wroteBased on interview and record review, the facility failed to ensure that alleged violations involving neglect were reported immediately but not later than 2 hours after the allegation is made if the event that caused the allegation resulted in serious bodily injury for 1 (Resident #1) of 5 residents reviewed for neglect. The Administrator failed to immediately report to HHSC within two hours after Resident #1 fell from a Hoyer lift during a transfer, which resulted in the resident sustaining a laceration to head requiring six staples at the hospital. This failure placed residents at risk of injury or worsening of their conditions.