Parklane West Healthcare Center

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 8 (Residents #103 and #66) residents in the dining area in that:The facility failed to deliver and serve meals to Residents #103 and #66 on time as posted on 7/14/2026, 7/15/2026 and 7/16/2026. Residents #103 and #66 were upset they had to wait to eat their food for anywhere from 30 to 40 minutes late. This failure could place residents that eat by mouth and could result in residents, not wanting to eat due to long period of time waiting and the loss of weight.

Inspectors wroteBased on interview and record review the facility failed to ensure that all residents had the right to formulate an advanced directive for 1 (Resident #5) out of 20 residents reviewed for advanced directives. The facility failed to ensure Resident #5's advance directive wishes were clearly identified and documented in the electronic health record. The resident was listed as full code, but had an active Out of Hospital Do not Resuscitate (OOH-DNR) form on file. This failure could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes.

Inspectors wroteBased on interviews and record review, the facility failed to ensure transmittal requirements within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 8 (Resident #6) residents reviewed for MDS assessments in that: MDS LVN C failed to transmit Resident #6's Quarterly MDS assessment within 14 days. Submitted on 7/13/2026. This failure could place residents at risk of not having their assessments transmitted timely and incomplete records.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the residents comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 (Resident #6) of 8 residents reviewed for care plans in that:The facility failed to ensure that Resident #6's care plan was reviewed and revised when the physician's order for oxygen was no longer active. This failure could place residents at risk of not receiving the care and services needed to meet their individualized needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #88) of 2 residents reviewed for incontinence and catheter care. CNA failed to change gloves and perform hand hygiene after cleaning and removing soiled brief while providing perineal and catheter care. This failure could place residents at risk of urinary tract infections from cross contamination.

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 1 of 1 refrigeration units reviewed for food safety requirements. The facility failed to ensure the refrigeration area was free from spills and debris. The facility failed to ensure food stored in the refrigeration areas was labeled properly with the contents and dates prepared/opened. These failures could place residents at risk of cross contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #2) of 8 residents reviewed for accuracy of clinical records in that:The facility failed to ensure Staff LVNs accurately documented in the July 2026 medication administration record that Resident #2 had completed the order for up in dining room for all meals with 1:1 feeding assistance. Before meals. Order date 03/01/2026 1335 (1:35 p.m.) This failure could result in inaccurate information in the clinical record and could place the residents at risk for errors in their care.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 10 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated to reflect Resident #1 had an incident of resident-to-resident verbal altercation on 04/17/2026. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident who is incontinent of bladder receives appropriate treatment and service to prevent urinary tract infections for 1 (Resident #2) of 2 residents reviewed for incontinent care in that: CNA-C and CNA-D placed Resident #2's indwelling urinary catheter bag above the level of the resident's bladder during transferring the resident from the bed to the wheelchair mechanically on 06/03/2026. This failure placed resident at risk for urinary tract infection, unwanted antibiotic therapy, and decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 (3rd floor medication aide cart and 2nd floor nursing cart) of 4 medication carts reviewed for medication storage. 1. The facility failed to ensure MA-E locked the 3rd floor medication aide cart when it was unattended on 06/03/2026. 2. The facility failed to ensure LVN-F locked the 2nd floor nursing cart when it was unattended on 06/04/2026. These failures could place residents at risk of not receiving prescribed medications as ordered and drug diversions. Findings Included:1. Observation on 06/03/2026 at 11:44 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 infections for 2 of 2 residents (Residents #1 and #2) reviewed for infection control. The facility failed to ensure MA A cleaned the blood pressure cuff between Resident #1 and Resident #2 on 03/17/2026. This deficient practice could place residents at risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 fire panels reviewed for essential equipment. The facility failed to ensure fire watch was adequately performed according to regulations and facility policy in January 2026-March 2026 when the facilities fire panel malfunctioned in January 2026 and was red tagged on 2/13/2026 and was ongoing. This failure could place residents at risk of injury from undetected fire and patient care equipment not in safe operating condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect or exploitation were reported no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency for 1 of 1 fire alarm/panels reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report to the State Survey Agency (HHSC) when the facilities fire alarm system and fire panel malfunctioned on 1/23/2026 and on 2/13/2026 when the fire alarm system panel was red tagged and in need of repairs and the facility continued on fire watch and was ongoing. This failure could place residents at risk for neglect from fire and physical harm from a malfunctioning fire alarm system.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #1, #2, and #3) reviewed for quality of life. The facility failed to ensure Residents #1, #2, and #3 had hot water in their own showers for showering for a warm and comfortable experience. This failure could place residents at risk for a decline in quality of life and health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 2 floors (2nd and 3rd floors) reviewed for physical environment, in that: The facility failed to ensure hot water temperatures were maintained between 100-110 degrees. This failure could place residents at-risk for uncomfortable water temperatures.

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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 3 residents (Residents #1 and #2) reviewed for care plans: 1. The facility failed to ensure Resident #1 comprehensive care plan included a plan with interventions to address her bathing and showering requirements. 2. The facility failed to ensure Resident #2's comprehensive care plan was developed to include interventions to address his ADL needs and requirements. These failures could place residents at risk of receiving improper care and services.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for medical records accuracy, in that: The facility failed to ensure Resident #1 Nursing Assistant ADL Flow Sheet was accurately documented from 1/21/2026 to 2/19/2026. This failure could place residents at risk for an incomplete clinical picture and errors in care and treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 5 Resident's room (Resident #2, 3, 4, 5, 6) reviewed for environmental concerns. Water temperatures were less than 100 degrees Fahrenheit in Resident #2, 3, 4, 6's room. Water temperature was more than 110 degrees Fahrenheit in Resident #5's room. This failure could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 8 residents (Residents #1 and #2) reviewed for pharmacy services. On 01/06/25, Resident #1 received the following medications late: Apixaban Oral Tablet 2.5 MG, Polyethylene Glycol 3350 Powder, Thiamine HCl Oral Tablet 100 MG, Multivitamin-Minerals Oral Tablet, Megestrol Acetate Oral Suspension 40 MG/ML, levETIRAcetam Oral Solution 500MG/5ML, Ascorbic Acid Oral Tablet 500 MG, Metoprolol Tartrate Oral Tablet 25 MG, and Lidocan External Patch 5%. On 01/07/25, Resident #1 received the following medications late: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure personal privacy for 1 of 2 residents (Resident #11) reviewed for privacy, in that: Resident #11 was observed in the hallway on 12/07/2025 with his foley bag attached to right calf without a privacy cover, exposing his foley bag contents to anyone in the hallway. This deficient practice could affect residents by resulting in loss of dignity and low self-esteem.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented for 3 of 3 residents (Resident #1, Resident #2, Resident #3) reviewed during the complaint investigation. The facility failed to ensure that Resident #1's treatment administration record noted treatments on 9.6.2025, 9.20.2025, 10.2.2025, 10.25.2025 as required by the orders noted on the electronic medical record. The facility failed to ensure that Resident #2's treatment administration record noted treatments on 9.2.2025, 11.5.2025 as required by the orders noted on the electronic medical record. The facility failed to ensure that Resident #3's treatment administration record noted treatments on 10.3.2025, 10.10.2025, 10.15.2025, 10.26.2025, 11.2.2025 as required by the orders noted on the electronic medical record. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed make sure that drugs were stored properly and only authorized persons had access to one of two carts reviewed for drug storage and labeling on Hall A 3rd floor. The facility failed to ensure the 3rd floor Hall A medication cart was locked and medications were secured and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings Included:Observation of 3rd floor Hall A medication cart on 11/25/2025 at 3:29 PM revealed it was unattended and locked with each drawer opening when pulled. LVN A was seated at the nurse's station and was ask to review the cart. The medication cart was up against the wall in the 3rd floor Hall A corridor. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 3 of 11 residents (Resident #1, Resident #2, and Resident #4) reviewed for clinical records. 1. The facility failed to obtain a physician's order to provide Resident #1 with indwelling catheter care and monitoring for 12 of 12 days (06/28/2025 to 07/09/2025) after admission and failed to ensure Resident #1's daily indwelling catheter care was documented in her medical record for 2 of 12 days (07/08/2025 and 07/09/2025). 2. The facility failed to obtain a physician's order to provide Resident #2 with indwelling catheter and monitoring for 2 of 3 days (06/22/2025 and 06/23/2025) after admission. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 2 of 4 (Residents #1 and #2) reviewed for assessments. 1. The MDS Coordinator failed to complete Resident #1's admission comprehensive assessment within 14 days after admission. MDS Coordinator A verified as complete on 07/12/2025. Resident #1 was admitted on [DATE]. 2. The MDS Coordinator failed to complete Resident #2's admission comprehensive assessment within 14 days after admission. MDS Coordinator A verified as complete on 07/13/2025. Resident #2 was admitted on [DATE]. This failure could affect newly admitted residents and result in residents not receiving the care and services as needed.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person- centered care of the residents that meets professional standards of quality of care within 48 hours of a resident's admission for 1 of 5 (Resident #1) reviewed for baseline care plans. The facility failed to include Resident #1's catheter care and monitoring in her initial baseline care plan dated 06/28/2025, when Resident #1 was admitted on [DATE]. This deficient practice could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life, infection, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who had an indwelling catheter received appropriate treatment and services to prevent urinary tract infections for 1 of 2 (Resident #3) reviewed for indwelling catheter care. 1. The facility failed to ensure CNA S cleaned Resident #3's indwelling catheter properly during incontinent care. 2. The facility failed to ensure Resident #3's indwelling catheter was secured appropriately and per physician's order. These failure could place residents with indwelling catheters at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 11 residents (Resident #4) reviewed for clinical records. The facility failed to ensure Resident #4's weekly skin assessments were documented in his medical record for 2 of 15 weeks (the weeks of: 05/15/2025 and 05/22/2025). These failures could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided.

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 2 of 2 residents (Resident #3 and Resident #5) and 2 of 2 staff (CNA S and CNA T) reviewed for infection control. 1. The facility failed to ensure CNA S properly secured her personal protective equipment during indwelling catheter and incontinent care for Resident #3 on 07/16/2025. 2. The facility failed to ensure CNA T wore appropriate PPE for EBP during indwelling catheter and incontinent care for Resident #5 on 07/16/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had a right to a safe, clean, comfortable, and homelike environment for 3 (Residents #147, #148 and #207) of 32 residents reviewed, in that: 1. The bathroom shower faucet handle used by Resident #147 and Resident #148 was broken. 2. The toileting chair used by Resident #207 had a rusty metal support frame with peeling paint in front of and under the seat. This failure could result in psychosocial harm due to diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 3 of 3 residents (Resident #34 , Resident #55, and Resident #74) whose records were reviewed for PASRR services. The facility failed to recognize during the Level I PASRR screening that Resident #34 and Resident #55 were diagnosed with major depressive disorder, while Resident #74 was diagnosed with schizoaffective disorder and bipolar disorder. This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnosis.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 28 residents (Residents #24, #247, #91, and #84) reviewed for comprehensive care plans in that: 1. Resident #24's diagnoses of allergies and constipation were not included in her care plan. 2. Resident #247's care plan was not updated to reflect the removal of his foley catheter. 3. Resident #91's care plan, initiated 03/11/2025 was not updated to reflect an order dated 05/09/2025 for a WanderGuard (a wander management system designed to help prevent residents from wandering off and potentially getting lost or injured). 4. [...]

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 1 of 1 facility in that: 1. The facility failed to maintain a garbage bin under the hand sink to collect dirty hand towels after use. 2. The facility failed to date a package of cheese and two 5 lb containers of cottage cheese in the refrigerator. 3. The facility failed to date a container of 7 ounces of dried rice in the dry storage room. 4. The facility failed to replace to overhead light bulbs in the dish machine room 5. The facility failed to cover two sections of floor baseboard in the main kitchen area that had an uncovered paint surface. 6. The facility failed to secure a ceiling tile in the main kitchen that showed exposed insulation underneath the tile. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 3 (Resident #10, Resident #24, and Resident #28) of 33 residents reviewed for medical records, in that: 1. Resident #10's clinical record included Nurse Practitioner notes which referred to another resident. 2. Resident #24's diagnosis of Osteoporosis was not included in her diagnoses list. 3. Resident #28's diagnosis of Depression was not included in her diagnoses list. These failures could result in inadequate care due to incomplete and inaccurate medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident environment that was free of pests for 1 of 1 facility reviewed for effective pest control in that: The facility failed to provide a resident environment that was free of pests as live roaches were observed in Resident #9's bathroom and in the facility conference room This deficient practice could result in illness and/or psychosocial harm for residents living in areas with insects.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #29) reviewed for call lights. The facility failed to ensure Resident #29's call light was within reach. This failure could place residents at risk of achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 (Resident #28) of 33 residents reviewed for advanced directives, in that: Resident #28's OOH-DNR was missing a physician's signature and was therefore invalid. This deficient practice could place residents at-risk of having their end of life wishes dishonored and of having CPR performed against their will.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #72) reviewed for privacy, in that: The facility failed to ensure that MA D locked the computer after she walked away and left the computer unattended , which exposed Resident #72's morning medication list . This failure could place residents at risk of having their medical information exposed to others and cause residents to feel uncomfortable and disrespected.

Inspectors wroteBased on interview and record review, the facility failed to assess each resident using the quarterly review instrument specified by the State and approved by CMS in a timely manner for 3 (Resident #54, #40, and #81), of 33 residents reviewed for timely assessment, in that: 1. Resident #54's Quarterly MDS, dated [DATE] and Annual MDS, dated [DATE] had been initiated but not completed. 2. Resident #40's Quarterly MDS, dated [DATE] and Quarterly MDS, dated [DATE] had been initiated but not completed. 3. Resident #81's Quarterly MDS, dated [DATE] had been initiated but not completed. This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information.

Inspectors wroteBased on interview and record review, the facility failed to encode and transmit resident assessments in a timely manner for 3 (Residents #200, #57, and #33) of 33 reviewed for resident assessments, in that: 1. Resident #57's Quarterly MDS, dated [DATE], was completed but not transmitted to CMS as of 05/14/2025. 2. Resident #33's Quarterly MDS, dated [DATE], was completed but not transmitted to CMS as of 05/14/2025. 3. Resident #200's Entry MDS, dated [DATE] was completed, but not transmitted to CMS within 14 days of completion. These deficient practices placed residents at risk of not having assessments completed and submitted in a timely manner as required.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 20 residents (Resident #72) reviewed for assessments: Resident #72's quarterly MDS, dated [DATE], did not include a diagnosis of depression. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 (Residents #211 and #200) of 8 residents reviewed for baseline care plans. 1. The facility failed to include Resident #211's use of anti-coagulants (medications that prevent or slow down the formation of blood clots) in his baseline care plan. 2. The facility failed to include Resident # 200's preference to receive a Kosher diet in her baseline care plan. This failure could result in residents not receiving needed care and treatment. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (excessive dose and duplicative therapy) for 1 of 6 residents (Resident #72) reviewed for unnecessary medicines, in that: The facility failed when in May 2025 Resident #72 received buspirone 5 mg twice a day for depression and Resident #72 received escitalopram 10 mg once a day for depression , reflecting a duplication of therapy when Psychotropic medications will not be given in excessive dosage. This failure could place residents at risk for adverse drug consequences and receiving unnecessary medications.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to have drugs and biologicals used in the facility labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable; and the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for 1 of 2 medication rooms (Hall 200 medication room) and 1 of 6 medication carts (300 Hall Nurse cart) reviewed for safe medication storage. The facility failed when: 1. There were 2 expired medications for Resident #72 stored on the shelf in the Hall 200 medication room on 05/15/2025. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual religious and cultural nutritional needs for 1 of 8 residents (Resident #200) reviewed for religious and cultural dietary needs. The facility failed to provide Resident #200 with a no pork Kosher diet (a diet which follows Jewish dietary laws, which has as a core principate that meat and dairy cannot be consumed together and only certain animals and birds are considered kosher) for the first 5 days after her admission on [DATE]. This deficient practice could place residents at risk for poor food intake, weight loss, and not having their religious nutritional preferences met.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to 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 disease and infection for 1 of 7 residents (Resident #9) reviewed for infection control, in that: The facility failed to ensure CNA-H consistently sanitized her hands in between glove changes while providing wound care for Resident #9 on 05/15/2025, This deficient practice could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 8 wheelchairs reviewed for essential equipment. The facility failed to ensure Resident #198's wheelchair brakes were functioning correctly on 05/13/2025. These failures could place residents at risk of not having functional and safe mode of mobility.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure each resident received food prepared in a form designed to meet individual needs, for 1 of 8 residents (Resident #1) reviewed for nutritional needs. The facility failed to provide a fortified meal plan from 1/4/2025 to 4/24/2025 for Resident #1 as ordered by the physician and the dietician. This failure could place residents at risk for harm by weight loss.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for one (Resident #1) out of three residents reviewed for documentation of wound care dressing changes. The facility failed to document wound care dressing changes on the Treatment Administration Record (TAR) for Resident #1 on 03/14/2025, 03/15/2025, 03/16/2025, 03/19/2025, 03/22/2025, and 03/23/2025. These failures placed residents at risk for missed treatments and care which could result in the wound deterioration, and development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for 2 of 3 residents (Resident #1 and #2) reviewed for pressure injuries. 1. The facility nurses did not provide wound care to Resident #1 on 03/20/2025 and 03/24/2025. However, the physician order indicated Cleanse left glute, lateral malleolus, medial calf, and right plantar with wound cleanser, gently pat dry with gauze, apply skin prep to peri wound, apply medi-honey, cover with calcium alginate and secure with dry dressing daily - every day. 2. The facility nurses did not provide wound care to Resident #2 on 03/25/2025. [...]

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 includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 7 residents (Resident #3) reviewed for care plans. The facility failed to develop a person-centered care plan with interventions that addressed Resident #3's ADL needs; indwelling catheter use; diagnoses and treatments including blood pressure, antidepressants, and antiplatelet medications; dietary needs, including requiring a mechanically altered diet; therapy; and discharge planning. This deficient practice could affect residents and place them at risk for not having their needs and preferences met.

Inspectors wroteBased on interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents for 1 of 3 residents (Resident #3) reviewed for medication administration. The facility failed to administer Carvedilol (a medication used to treat HTN) to Resident #3 per physician's orders. This deficient practice could place residents at risk of not receiving the therapeutic benefit of prescribed medication or a decline in health.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 7 residents (Resident #3) reviewed for clinical records. The facility failed to ensure Resident #3's EMR reflected accurate HR on 10/20/24. These failures could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to transcribe Resident #1's discharge orders and failed to follow-up to ensure Resident #1's hospital discharge orders were implemented timely, which caused him to miss getting his medications for four (4) to five (5) days. This failure could cause a delay in appropriate medical care and worsening in symptoms, condition, or illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment ans supports for daily living safely for 4 of 30 rooms (Rooms #309, #316, #328, and #330) on the third floor of the facility and 1 of 3 halls (Hall C) on the third floor of the facility, in that: 1. The facility failed to repair a wall scrape behind a resident bed in room [ROOM NUMBER]. 2. The facility failed to repair a wall scrape behind a resident bed in room [ROOM NUMBER]. 3. There were 2 of 3 light bulbs burnt in room [ROOM NUMBER]. 4. The wall between Rooms #328 and #330 showed signs of water damaged. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident received food that was served at a safe and appetizing temperature for 2 (Residents #1 and #77) of 22 Residents reviewed for palatable food in that: Residents #1 and #77 reported receiving cold food at mealtimes. This failure could place residents at risk of not being satisfied with their food or encouraged to increase their personal food intake with an outcome of weight loss and a diminished 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 for 1 of 1 kitchen. 1. [NAME] A was preparing food in the kitchen and did not have a facial hair restraint covering his facial hair. 2. The DM wore jewelry on his wrist while engaged in food preparation in the kitchen. 3. In the walk-in cooler there was a quart of heavy cream that was opened and not labeled with a use-by date and a container of Thickened Dairy Beverage past the use-by date. 4. In the dry storage room there were two small plastic bowls filled with crispy rice cereal that were not sealed, labeled and dated, and a #10 can of tomatoes on the floor. 5. The tabletop can opener blade, bar, and base were covered in sticky black and brown grime. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident 4) reviewed for care plans. The facility failed to care plan Resident #4's self-care for colostomy. This failure could place residents at risk of not having their needs met. Finding Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 1 of 5 residents (Resident #4) reviewed for medication storage, in that: The facility failed to ensure medications were not left on Resident #4's bed side table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 disease and infection for 1 of 7 residents (Resident #58) reviewed for infection control, in that: While administering medications for Resident #58, RN E touched the light fixture pull cord and power plug and, the bed remote with her gloved hands and did not changed her gloves and washed her hands before touching Resident #58's eyes area and administering eye drops to the resident. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 facility. The facility failed to maintain the garbage storage area in a sanitary condition to prevent the harborage and feeding of pests. This failure could place residents at risk of having contact with pests from an unsanitary garbage storage area.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to a resident who is unable to carry out activities of daily living received the necessary services to maintain grooming for 1 of 6 residents (Resident #2), reviewed for activities of daily living, bathing and grooming, in that: Resident #2 was not provided with grooming of her facial chin hair which appeared to measure over a quarter of an inch. This deficient practice could result in residents experiencing a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide for a resident who is incontinent of bladder appropriate treatment, and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #5) reviewed for catheter care, in that: Resident #5's urinary catheter bag with urine was not anchored to the bed frame and lying on the floor. This deficiency could prevent residents on catheter treatment from receiving appropriate services and could lead to blockage in urine flow and infection.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodations of residents needs and preferences for 3 of 6 residents (Residents #1 #2, and #4) reviewed for accommodations of needs. The facility failed to ensure Residents (#1, #2, and #4,) call lights were answered in a timely manner when they needed assistance. This failure could place residents at risk of not receiving care or attention needed.

Inspectors wroteBased on observations, interviews, and record review failed to ensure that it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident for 4 of 6(Residents #1, #2,#3,#4,) residents. 1. The Administrator failed to ensure nursing staff were performing showers on Residents (1,2,3,4) causing the residents to receive no showers or only 3 showers in a two week period. 2. The Administrator failed to ensure all staff were answering resident call lights in a timely manner when they needed assistance. This could place residents at risk of not receiving care or attention needed.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the necessary services to maintain good personal hygiene for 4 of 5 residents (Residents #1, #2, #3, and #4,) reviewed for activities of daily living. 1. Resident #1 had no showers between dates of 12/29/2023-1/7/2024. 2. Resident #2 had 3 showers between dates of 12/25/2023-1/7/2024. 3. Resident #3 had 2 showers between dates of 12/25/2023-1/7/2024. 4. Resident #4 had 2 showers between dates of 12/25/2023-1/7/2024. This failure could affect residents and contributed to feelings of hopelessness and frustration.

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 1 of 15 residents (Resident #5) and for 1 of 1 facility in that: The facility failed to adequately clean a resident dining room following meal service, clean a table over a two-day period, clean a spilled liquid area in cabinet holding the juice machine pump, repair broken shelving in a kitchen cabinet, repair a broken piece of kitchen cabinet surface, repair a broken kitchen cabinet door hinge, replace three missing ceiling tiles, and repair a resident's broken window blind. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident representative for 1 of 1 resident (Resident #1) reviewed for changes in condition. The facility failed to notify the Resident's # 1 's family member of a positive pneumonia diagnosis. This deficient practice could result in denial of resident rights of family to be notified with any change of status criteria. Failure to notify family members of significant change of status could affect any resident at risk for hospitalization. Findings Included: Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] diagnosis that included: [...]

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 1 of 1 kitchen, in that: The facility failed to ensure all staff were wearing hairnets while in the kitchen. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.