Parkview Skilled Care and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (Kitchen A) reviewed for dietary services. The facility failed to allow the food processor container to air dry completely before using it to puree food on 8/4/26 and 8/5/26. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 8 residents (Resident #74 and Resident #84) reviewed for advanced directives, in that: The facility failed to ensure Resident #74 and Resident #84 had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that did not have missed required information. These failures could place residents at risk for not having their end-of-life wishes honored and incomplete records.

Inspectors wroteBased on Observations, Interviews, and Record Review the facility failed to ensure residents were free from involuntary seclusion for 1 of 22 (Resident #7) residents reviewed for involuntary seclusion. The facility failed to obtain a physician order, documenting the clinical criteria met for placement in the secure/locked unit for Resident #7 on 08/04/2026. This failure could place residents at risk of isolation, decreased quality of life, and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and maintained in accordance with currently accepted professional standards for 1 of 2 medication carts (Medication Cart 1) reviewed for storage. The facility failed to ensure CMA C ensured Medication Cart 1 was locked before walking into room [ROOM NUMBER] on 8/5/2026. This failure could result in misappropriation of medication, or medication errors.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure menus were followed for 1 of 2 meals observed. (Lunch meal 8/4/26) The facility failed to follow the week 5 menu for pureed lunch meals served at the facility on Tuesday 8/4/26 by not serving or substituting all food items listed on the menu. This failure could place residents that eat food from the kitchen at risk of poor intake, and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #9) residents reviewed for infection control. The facility failed to ensure CNA B utilize EBP during wound care for Resident #9 on 8/05/2026. This failure could place residents at risk for cross contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were developed in consultation with the resident and the resident's representative for 4 of 6 residents (Resident #66, Resident #11, Resident #51, and Resident #38) reviewed for comprehensive care plan in that: The facility failed to ensure Resident #66, Resident #11, Resident #51 and Resident #38 or the resident's representative were invited to participate in the resident's care plan meetings. This failure could place residents at risk of not receiving the interventions, treatments and care necessary for the residents to reach their highest practicable physical, mental, and psychosocial well-being by not involving the residents and/or resident's representatives in care plan meetings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 22 confidential residents. The facility failed to ensure confidential residents were provided access to the Grievance form and provided the procedure for how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 2 of 22 residents (Residents #59 and #62) reviewed for PASRR screening, in that: Residents #59 and #62 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of mental illness. These failures could place residents with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview 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, and documented, that it was appropriate for the PRN order to be extended beyond 14 days for 1 of 1 resident (Resident #61) reviewed for PRN psychotropic medications, in that: Resident #61 continued to have a PRN order for Lorazepam 2 MG/ML after 14 days without a duration. This failure could result in residents receiving antipsychotic medications when contraindicated and could result in residents experiencing adverse drug reactions.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #185) of 4 residents reviewed for medication administration. The facility failed to ensure metoclopramide (used to increase muscle contraction in the upper digestive tract) administered to Resident #185 as ordered. This failure could place residents at risk for not receiving medications as ordered by their physician.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 meal (lunch meal 06/11/25) reviewed for dietary services, in that: The facility failed to ensure hot foods were maintained at 135 degrees F and above. These failures could place residents at risk of food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Residents #17) reviewed for infection control. CNA A failed to change gloves and utilize hand hygiene during incontinence care with Resident #17. This failure could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interviews and record review, the facility failed to develop and implement abuse policies and procedures to prohibit, prevent and investigate allegations of abuse for 1 of 6 residents (Resident #1) reviewed for abuse. The Facility failed to establish abuse policies and procedures that mandate reporting of all allegations of abuse to the State Agency when Resident #1 made an outcry of abuse. The Facility failed to establish abuse policies and procedures that ensure reporting of all findings of allegations of abuse to the State Agency within five days of knowledge of the alleged abuse. These failures could place residents as risk for abuse and neglect.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure all allegations of abuse were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to other officials, including the State Survey Agency for 1 of 6 residents (Resident #1) reviewed for abuse. The Administrator failed to report allegations of abuse to HHSC when Resident #1's alleged abuse against LVN C. This failure could place residents as risk for abuse and neglect.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be free from abuse for one (Resident #1) of six residents reviewed for abuse. The facility failed to ensure a safe environment free from abuse for Resident #1, who was combative, when CNA A and NA B continued to provide her care before, during, and after her shower. This failure could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of six residents reviewed for dementia care. The facility failed to comprehensively assess the physical, mental, and psychosocial needs of Resident #1, who had dementia, and identify the risks and/or to determine underlying causes after she became combative before, during and after her shower. This facility's failure could place residents with dementia at risk for their medical, physical, and psychological needs not being met and resulting in a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to ensure foods were stored under sanitary conditions. 2) The facility failed to ensure food and nonfood contact surfaces were clean. 3) The facility failed to ensure foods were in sound condition 4) The facility failed to ensure food storage areas were clean and good condition 5) The facility failed to ensure food contact items were stored in a sanitary manner 6) The facility failed to ensure hair restraints were worn in food areas 7) The facility failed to ensure manufacturers guidelines were followed regarding food retention These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible in 2 of 4 common resident baths (200 and 400), and 1 of 4 halls (400) in that: The facility failed to ensure chemicals were not accessible to residents and were not stored with resident toiletries and personal items in 2 of 4 common resident baths (200 and 400), and 1 of 4 halls (400). These failures could lead to chemical associated resident injuries.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 residents (Residents #50 and #76) reviewed for infection control. 1. CNA C failed to utilize proper hand hygiene during incontinence care for Resident #50. 2. CNA D failed to utilize proper hand hygiene during incontinence care for Resident # 76. These failures could place residents at risk for infection and cross contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure to address, resolve and have a prompt resolution of all grievances in accordance with facility policy for 1 of 9 (Resident #4 ) residents, in that: [...]

Inspectors wroteBased on, interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 9 residents (Residents #1) reviewed for abuse and neglect. 1. A confidential facility staff member willing and knowingly failed to report allegations of abuse regarding Resident #1 to the abuse coordinator after Resident #1 reported CNA D physically and verbally abused Resident #1 (date and time of incident was not specified). 2. The Administrator failed to reassign CNA D to duties that did not involve patient care after she was notified on 04/15/24 by the HHSC worker that CNA D was named in an allegation of abuse by resident #1. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the environment was free of accident hazards and supervision of staff for 2 out of 9 (#2 and #3) residents who required mechanical lift transfers. 1. 3 confidential interviews revealed they transferred residents alone with a mechanical lift which required 2 people for safety. 2. Resident #2 confirmed that staff (unnamed) transferred them with the mechanical lift with one staff on a regular basis. 3. Resident #3 confirmed that staff (unnamed) transferred them with the mechanical lift with one staff and that he had almost fallen out of the mechanical lift 2 months ago because the sling strap was not secured properly. 4. [...]