The Center at Parmer

Inspectors wroteBased on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and 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 8 sampled residents (R#68). The facility failed to develop a care plan that described the respiratory care/services R#68 would receive for her shortness of breath per her physician's orders made on 10/25/25. This failure could place residents at risk of receiving the wrong oxygen flow, interruptions in therapy, delayed emergency response, respiratory distress, life-threatening hypoxia or complications from oxygenation. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 8 sampled residents (R#63). The facility failed to revise R#63's care plan to reflect all fall risk interventions recommended by the PCP after his unwitnessed fall on 01/13/26. This failure could place residents at risk of falls, injuries or hospitalization. Review of R#63's admission record, dated 01/29/26, showed he was admitted to the facility on [DATE] with medical diagnoses including wedge compression fracture, low back pain and altered mental status. Review of R#63's 5-Day MDS assessment, dated 01/15/26, showed he had a BIMS score of 7/15, which indicated he had severe cognitive impairment. Section J reflected he had no falls since admission/reentry. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 sampled residents (R#63). The facility failed to conduct neurological monitoring for R#63 after his unwitnessed fall on 01/13/26. These failures could place residents at risk of delayed treatment adjustments or potential health complications. Review of R#63's admission record, dated 01/29/26, showed he was admitted to the facility on [DATE] with medical diagnoses including wedge compression fracture, low back pain and altered mental status. Review of R#63's 5-Day MDS assessment, dated 01/15/26, showed he had a BIMS score of 7/15, which indicated he had severe cognitive impairment. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 8 sampled residents (R#11 and R#68). 1. The facility failed to bag R#11 and R#68's NCs, CPAP masks, and tubing when not in use.2. The facility failed to document oxygen liters in R#11 and R#68's TARs per their physician's orders. This failure could place residents at risk of respiratory infection. Review of R#11's admission record, dated 01/28/26, showed she was admitted to the facility on [DATE] with medical diagnoses including acute respiratory failure, asthma, pneumonia and COVID-19. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 8 sampled residents (R#63). CNA A failed to lower R#63's bed per physician's orders after performing resident care and exiting his room on 01/28/26 at 11:47 a.m. This failure could place residents at risk of falls, injuries and hospitalization. Review of R#63's admission record, dated 01/29/26, showed he was admitted to the facility on [DATE] with medical diagnoses including wedge compression fracture, low back pain and altered mental status. Review of R#63's 5-Day MDS assessment, dated 01/15/26, showed he had a BIMS score of 7/15, which indicated he had severe cognitive impairment. Section J reflected he had no falls since admission/reentry. [...]

Inspectors wroteBased on interviews and record review, the facility failed to comprehensively assess within 14 days after the facility determined, or should have determined, that there has been a significant change in resident's physical or mental condition for 1 of 8 sampled residents (R#7). 1. The facility failed to complete a significant change assessment within 14 days of determining R#7 had 5% or more significant weight loss. 2. The facility failed to document R#7's weekly weights per her physician's order. This failure could place residents at risk of inadequate care planning or not receiving appropriate care. [...]

Inspectors wroteBased on interviews and record reviews, 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 #1) of five residents reviewed for quality of care. The facility delayed Resident #1's catheter care for approximately 2.50 hours on 09/02/25 resulting in Resident #1 having discomfort and pain. This failure could place residents at risk of discomfort and pain, a decrease in their quality of life, quality of care, and dignity.

Inspectors wroteBased on interviews and record review the facility failed to ensure the medical record on each resident was complete and accurately documented for one (Resident #1) of five residents reviewed for accurate medical records. The facility documented in Resident #1's MAR that he received catheter care at 10:00 pm on 09/02/25 when Resident #1 stated he received catheter at approximately 6:30 pm on 09/02/25. This failure could place residents at risk of misdiagnosis, incorrect treatment, and poor quality of life.

Inspectors wroteBased on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, ensure that all alleged violations are reported to the state survey agency immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse for one (1) of five (5) residents reviewed for abuse and neglect. (Resident #1). The facility failed to report an alleged abuse incident reported by Resident #1 on 06/19/2025 to the State Agency when Resident#1 alleged CNA B pushed her. This deficient practice placed all residents at risk of harm from abuse due to not having a thorough investigation done for an alleged abuseFindings Include: Record review of Resident #1's face sheet, dated 07/15/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

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 one (1) of five (5) residents reviewed for abuse and neglect. (Resident #1). The facility failed to thoroughly investigate an alleged abuse incident reported by Resident #1 on 06/19/2025 when Resident #1 alleged being pushed by CNA B. This deficient practice placed all residents at risk of harm from abuse due to not having a thorough investigation done for an alleged abuse. Findings Include: Record review of Resident #1's face sheet, dated 07/15/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 6 residents reviewed for discharge planning. 1. The facility failed to notify Resident #1 and Resident #1's RP of Resident #1's discharge, reasons for the move, and right to appeal in writing, in a language and manner they understand, and at least 30 days before Resident #1 was discharged from the facility on 06/11/25. 2. The facility failed to send a copy of the notice to the facility's Ombudsman before Resident #1 was discharged from the facility on 06/11/25. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement a comprehensive care plan to meet the medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being of 3 (Resident #235, Resident #242, and Resident #289) of 6 residents reviewed for care plans. The facility failed to complete an accurate comprehensive care plan for Resident #235, Resident #242, and Resident #289 by not including assistance required during transfer. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided during transfers leading to falls and hospitalizations. [...]

Inspectors wroteBased on interviews and record review, the facility failed to transmit a resident assessment within the required time frame for 1 of 4 discharged residents (Resident #61) reviewed for data encoding and transmission. in that: Resident #61's Discharge MDS was not encoded or transmitted as of 07/22/2024. This failure affected residents who have been discharged in the last 30 days at risk of not having their assessments transmitted timely.

Inspectors wroteBased on interviews and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 residents of 24 residents (Resident #11, Resident #18, and Resident #285) reviewed for activities. 1. Residents #11, Resident #18, and Resident #285 were not engaged in a person-centered activity programs and said they were bored. 2. The group activity calendar for the month of September 2024 listed an entry of books, puzzles, and TV Time for each day, no other activities listed. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 1 of 1 Residents (Resident #73) reviewed for tracheostomy care. The facility failed to ensure Resident #73 used aseptic technique (a procedure that healthcare providers use to prevent the spread of germs that cause infection. Placing barriers, using sterile equipment, and following strict guidelines that help create an environment free of germs.) during tracheostomy care. The facility further failed to ensure that Resident #73's tracheostomy tube was free from secretions to ensure a patent airway prior to inserting his inner cannula. This failure could place residents who use respiratory equipment and have tracheostomies at risk for respiratory infections and respiratory distress.

Inspectors wroteBased on observations, interviews, 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 and follow accepted national standards for one of one resident reviewed for tracheotomy care (Resident #73). The facility failed to ensure LVN F used aseptic technique during tracheotomy care for Resident #73. These failures could place residents at risk for developing wound and upper respiratory infections.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment for 4 (Residents #1, 2, 3, and 4) of 6 residents reviewed for comprehensive care plans, in that: The facility failed to complete a comprehensive person-centered care plan to address Residents #1, 2, 3, and 4's needs within seven days after the comprehensive MDS assessment were completed. 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.

Inspectors wroteBased on interview and record review, the facility failed to include as part of its QAPI program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program, for 11 of the 11 staff members reviewed for mandatory training, in that: All eleven staff members reviewed for mandatory training had not received training regarding the facility's QAPI program. This failure could place residents at risk of receiving inadequate care from staff who are unfamiliar with the facility's QAPI program.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure their medication error rate was not 5 percent or greater and had a medication error rate of 30.77% percent with 26 medications administration opportunities observed with 8 errors for 2 of 5 residents (Residents #39 and #195) and 1 of 2 staff (RN A) reviewed for medication administration, in that: 1. RN A administered the incorrect dosage of diltiazem to Resident #39. 2. RN A administered 4 medications to Resident #39 with no physician orders. 3. RN A crushed all of Resident #39's medications in the same bag, 2 medications were extended release (Do NOT Crush) and administered them to Resident #39. 4. RN A did not observe administration of 1 medication for Resident #195. 5. RN A allowed Resident #195 to self-administer a medication when the order did not allow for self-administration. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete an assessment which accurately reflected the resident's status for 1 of 24 (Resident #7) residents reviewed, in that: Resident #7's use of antipsychotics were not included in the resident's admission MDS assessments. This failure could result in inadequate care due to an incomplete assessment of her psychological condition.

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 to help prevent the development and transmission of infections for 1 of 3 staff (LVN B) reviewed for infection control, in that: LVN B did not sanitize her hands prior to setting up wound care supplies for Resident #19. These deficient practices could place residents who receive wound care or catheter care at-risk for infections.