The Parks at Garland Healthcare and Rehab

Based on observation, interview, and record review the facility failed to provide a private meeting space for residents' monthly Resident Council Meeting for 7 of 14 confidential residents reviewed for Resident Council for 1 of 1 facility.1. The facility failed to provide a private space area for residents who attended monthly Resident Council Meetings.This failure could place residents who attend the monthly Resident Council Meetings at risk of not being able to voice their concerns amongst each other due to a lack of privacy.Findings included:In an interview with the Activities Director on 04/09/26 at 10:30 AM, she stated that the confidential group meeting on 04/09/26 with the residents of Resident Council and the State Surveyor would not be held in the Private Dining Room where the monthly Resident Council Meetings were normally held. The Activities Director stated that the confidential group meeting on 04/09/26 with the residents of Resident Council and the State Surveyor would be held in an empty resident room for privacy.A confidential group meeting was held on 04/09/26 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the right to file grievances anonymously for 12 of 12 residents (Resident #75 and confidential group members) reviewed for grievances.1. The facility failed to ensure that the 93 residents at the facility had access to file a grievance anonymously.The facility's failure could place the residents at risk for concerns not being reported and addressed.Findings included:Record review of Resident #75's Face Sheet, dated 04/10/26, reflected she was a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident # 75's active diagnoses included: Stage 3A chronic kidney disease (mild to moderate loss of kidney function), Alzheimer's disease (a progressive, neurodegenerative disorder and the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), dementia (cognitive decline-including memory loss, language issues, and poor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a discharge summary for 1 of 3 residents (Resident #2) reviewed for closed records. The facility failed to ensure Resident #2 discharged the facility with a discharge summary that included an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions to ensure that care is coordinated and the resident transitions safely from one setting to another. This failure could place residents at risk for not receiving appropriate and timely care due to confusion among various facilities, agencies, practitioners, and caregivers involved with the resident's care. Findings Included: Record review of Resident #2's discharge MDS, dated [DATE], revealed the [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's disease (a fatal neurological disorder) and discharged the facility on 03/21/2026. A record review of Resident #2's progress notes, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 5 residents (Resident #1) reviewed for infection control. CNA A failed to wear the appropriate PPE while providing incontinent care to Resident #1.CNA B failed to wear the appropriate PPE while transferring Resident #1 from bed to wheelchair. LVN C failed to wear the appropriate PPE while transferring Resident #1 from bed to wheelchair. This failure could place residents at risk of being infected by staff in contact with other residents with infections. Review of Resident 1's Quarterly MDS assessment dated [DATE] revealed that she was a [AGE] year-old female. Resident #1 was re-admitted to the facility on [DATE]. Admitting diagnoses included muscle wasting and atrophy, muscle weakness (generalized), morbid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meals tested for nutritive value, flavor, and appearance: The facility failed to provide palatable food served at an appetizing temperature to residents, during lunch on 12/09/2025. This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served.The findings included: During an interview on 12/09/2025 at 9:58 a.m., CNA A stated she had received complaints from residents that the food was cold, but not often and only for residents who ate in their room. The CNA stated that trays were passed when the cart was on the hall. The CNA stated that it could take 10 minutes to pass all trays. During an interview on 12/09/2025 at 10:10 a.m., CNA G stated she had received complaints from residents stating that the food was cold. The CNA G stated that they asked the residents if they would like…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of2 residents reviewed for misappropriation (Resident #2). Based on interview and record review, the facility was unable to account for 11 Soma pills missing from Resident #2's blister pack of physician prescribed Soma (muscle relaxant). This failure could place residents at risk of misappropriation of physician ordered medications. Findings included: Record review of the Quarterly MDS dated [DATE] reflected indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Congestive Heart Failure (heart pumps slow), Schizoaffective (mental disorder), panic disorder (mental disorder), dementia (confusion), diabetes, (increased sugar), other chronic pain (pain). Resident #2 was severely cognitively impaired and unable to make decisions. Resident #2 requires two staff for activities of daily living. Record review of a Physician's Order dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #1) of 2 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. Findings included: Record review of Resident #1's quarterly MDS dated [DATE] revealed a [AGE] year-old male, admitted to the facility on [DATE]. He had the following diagnoses: muscle weakness (decreased strength), drug induced movement disorder (involuntary movements), unspecified lack of coordination (unable to control movement), diabetes (increased sugar), genetic related intellectual disabilities (abnormalities in genes or chromosomes), seizure (nerve disorder),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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 only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure staff were wearing the appropriate hair and beard coverings. This failure could place residents at risk for food contamination and foodborne illness. Findings included: Observation on 01/29/25 at 11:36 AM of the kitchen revealed Dietary Manager (DM) had facial hair on his chin, and he was not wearing a beard covering. The DM was observed checking temperatures of the food they prepared for the lunch meal service. In an interview on 01/30/25 at 03:35 PM, the DM stated that he had been the DM for over a year. He was made aware that during food temperatures he did not have a beard covering and that the Environmental. Director was observed taking food off the tray stand and delivered food to residents and he was not wearing a beard covering. The DM revealed he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a comprehensive plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, that includes but is not limited the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, and a member of food and nutrition services staff, for one of three residents (Resident #1) reviewed for comprehensive resident centered care plans. The facility failed to ensure all members of the interdisciplinary team were present for the care plan. The failure placed the residents at risk for unmet care needs and a decreased quality of life. Findings included: Record review of Resident #1's electronic face sheet, printed 3/26/2024, revealed a [AGE] year-old male was admitted to the facility on [DATE] and re admitted on [DATE] and 03/20/24 with diagnoses that included but not limited to pressure ulcer (areas of skin damage caused…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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 the facility's only kitchen. 1. The facility failed to date food stored in the freezer that should no longer be consumed. 2. The facility failed to discard food stored in the refrigerator that was past use by date and should no longer be consumed. These failures could affect Residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination. Findings included: Observation in facility's kitchen on 12/05/23 at 09:25 AM revealed Whipped topping in freezer was not dated. Observation in facility's kitchen on 12/05/23 at 09:28 AM revealed whole frozen turkey found in the kitchen walk-in freezer in original packaging was not dated. Observation in facility's kitchen on 12/05/23 at 09:31 AM revealed spoiled Lettuce stored in walk-in refrigerator with use-by date of 11/26/2023. In an interview with FSD on 12/05/2023 at 9:47…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each Resident, consistent with Resident rights, that include measurable objectives and time frames to meet Residents' mental and psychosocial needs for 2 of 4 (Residents #6 and Resident#235) Residents reviewed for care plans. 1) The facility did not develop and implement a comprehensive person-centered care plan to address Resident # 6 noncompliance with Physician orders of using O2 via Nasal cannula. 2) The facility did not develop and implement a comprehensive person-centered care plan to address Resident #235 Significant weight loss of 8.64% in 1 month.) This failure could place resident at risk of not having a plan developed to address care needs. Findings include: Resident #6 Record Review of Resident # 6 MDS dated [DATE] revealed that Resident #6 was a [AGE] year-old female admitted to facility on 06/3/2023 with BIMS Score of 13 which means that resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to conduct activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Resident #1, Resident #2, Resident #3) of 5 residents reviewed for ADL care. The facility failed to ensure Resident #1's facial hair was removed and nails were trimmed and cleaned. The facility failed to ensure Resident #2's facial hair was removed. The facility failed to ensure Resident #3's nails were trimmed and cleaned. These failures could place residents at risk of infections and skin tears resulting in pain, discomfort and decreased psycho-social well-being and self-worth. Findings included: Record review of Resident #1s Quarterly MDS assessment dated [DATE] revealed he was a [AGE] year-old male admitted on [DATE]. He had a BIMs of 15 (cognitively intact) and required extensive assistance with ADLs. He had diagnoses of blindness, stroke, hemiplegia (one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that each resident received adequate supervision/assistance to prevent accidents for one (Resident #1) of four residents reviewed for accidents in that: Agency CNA A failed to utilize the appropriate safety precautions and amount of assistance Resident #1 required while providing incontinence care for the resident, as a result, Resident #1 rolled out of the bed and sustained a black eye. This failure could place residents at risk for accidents and injury. Findings included: Review of Resident #1's facility electronic face sheet, undated, reflected the resident was a [AGE] year-old male who admitted on [DATE] with diagnoses of dementia and muscle weakness. Review of the Minimum Data Set (MDS ) assessment dated [DATE] revealed Resident #1 required total assistance of two staff members for activities of daily living (ADL), including incontinence care and bed mobility. Further review of the MDS revealed a Brief interview of mental status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1(bathroom room [ROOM NUMBER]) of 6 bathrooms reviewed for pest control The facility failed to ensure Resident bathrooms did not contain live roaches. This failure could place residents at risk of a diminished quality of life due to an unsafe environment. The findings were: Observation on 09/12/2023 10:45 a.m. revealed a live roach on Resident #2 and Resident #3's bathroom ceiling. The bathroom had a dead roach on the floor of the shower. Interview on 09/12/2023 at 10:35 AM with Resident #2 revealed she had lived in the facility off an on for 4 years. She stated she had complained of roaches being in the room and maintenance did spray bug spray however the issue had not been resolved. Resident #2 stated she did file a grievance regarding the roaches however did not remember the exact date. Resident #2 was not sure how long there has been issues with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.