Park Manor Of The Woodlands

Based 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 reviewed for food procurement in 1 of 1 kitchen to demonstrate the prevalence of the noncompliance in that: -The facility failed to ensure 10 pounds of raw fish was stored at proper temperature. -The facility failed to ensure scoops were not stored in food bins. -The facility failed to ensure gallons of milk were not stored on a rack 4 1/2 inches off the floor. These failures could place residents at risk of food borne illnesses and diseases. Observation and interview on 9/09/25 between 8:30 am and 8:40 am with the Dietary Manager revealed the following: -10 pounds of raw fish was inappropriately being held on a pan being thawed at room temperature, evidenced by taking the temperature revealed the internal temperatures of 64 degrees Fahrenheit. -Scoops with handles submerged in the sugar bin and flour bin. -4 gallons of milk were on a rack 4 1/2 inches off the floor in the walk-in refrigerator.…

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 3 of 3 residents (Resident #75, Resident #78 and Resident #79) and 1 of 1 Kitchen (Kitchen A) reviewed for infection control. 1.The facility failed to ensure MA E used the required PPE for Resident #75, who was on enhanced barrier precautions, while checking BP on 9/23 /25. 2. The facility failed to ensure LVN K used the required PPE for Resident #78 on 9/23/25. 3. The facility failed to ensure CNA B maintained hand hygiene during incontinent/FC on 9/24/25 for Resident #79. 4. The facility failed to ensure CNA B cleansed around the buttocks for Resident #79 on 9/24/2025. These failures could place residents at risk of cross-contamination, development of infections, and food-borne illnesses and diseases.1.Record…

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 a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (Resident #79) reviewed for ADL care. The facility failed to ensure CNA B cleaned Resident #79 properly during incontinent care on 9/24/25.This failure could place residents at risk for pain, infection and hospitalization.Record review of Resident #79's face sheet reflected the date of admission was 8/27/25 and readmitted on [DATE]. Resident #79 had diagnoses which included history of generalized anxiety disorder, other specified depressive episodes, obesity, class 1( excess body fat0, other specified hypothyroidism, other hyperlipidemia(high lipid/fat in the blood), gastro-esophageal reflux disease without esophagitis, pneumonia due to other specified bacteria, other acute kidney failure, essential (primary) hypertension (high blood pressure),…

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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #79) reviewed for incontinent care. 1.The facility failed to ensure CNA B properly cleaned Resident #79's indwelling Foley catheter.2. The facility failed to ensure CNA B followed proper hand hygiene during incontinent care on 9/24/25.3. The facility failed to ensure CNA A secured Resident #79's Foley catheter. These failures could place residents at risk for pain, infection, injury, and hospitalization.Record review of Resident #79's face sheet reflected the date of admission was 8/27/25 and readmitted on [DATE]. Resident #79 had diagnoses which included history of generalized anxiety disorder, other specified depressive episodes, obesity, class 1(excess body fat, other specified hypothyroidism(e03.8), other hyperlipidemia(high…

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 a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and prevent complications of enteral feedings including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #78) reviewed for feeding tubes. The facility staff failed to ensure LVN K verified placement of Resident #78's feeding tube prior to medication administration on 9/23/25. This failure could place residents at risk for complications such as aspiration pneumonia (occurs when food or liquid is breathed into the airway or lungs, instead of being swallowed), pneumothorax (a condition that occurs when air leaks into the space between the lungs and chest wall), perforations, empyema (one of the diseases that compromises chronic obstructive pulmonary disease), bronchopleural fistula (a sinus tract…

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, in accordance with accepted professional standards and practices, medical records on each resident were maintained that were complete and accurately documented for 1 of 6 residents (Resident #144) reviewed for accurate records.-The facility failed to ensure urine output was documented on 9/14/2025 and 9/19/2025 per physician orders for Resident #144.This failure could place residents at risk of changes in condition not being detected and treated in a timely manner. Record review of Resident #144's face sheet, dated 09/25/2025, reflected a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included type 2 diabetes mellitus (high blood sugar), neuromuscular dysfunction of bladder (damage or dysfunction in the nerves or muscles that control bladder function), rheumatoid arthritis (chronic inflammatory disorder affecting small joints in the hands and feet), and extended spectrum beta lactamase…

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 that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 16% based on 4 errors out of 25 opportunities, which involved 1 of 8 residents (Resident #99) reviewed for medication errors. -The facility failed to ensure LVN N administered the correct dose of Potassium Chloride or Ferrous sulfate liquid to Resident #99 according to Physician orders. -The facility failed to ensure LVN N did not crush and administer; Acetaminophen ER (an extended-release formulation which should not be crushed) to Resident #99 via g-tube (a way to deliver liquid nutrition through a flexible tube to your digestive system) instead of Acetaminophen as ordered by the Physician. These failures could place residents at risk of inadequate therapeutic outcomes. Findings include: Record review of Resident #99's face sheet dated 8/8/24 revealed an [AGE] year-old female readmitted on [DATE]. Her diagnoses included…

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 observation the facility failed to ensure residents received drinks consistent with preference and sufficient to maintain hydration for 10 of 10 (confidential group) and 3 of 21 (Resident #1, Resident #2, and Resident # 78) of residents reviewed for hydration. The facility did not provide hot coffee to residents during mealtimes. This failure could place residents who depend on the facility for their hydration needs at risk for thirst, dehydration, and decreased quality of life. Findings included: Record review Resident #1's face sheet revealed resident admitted to the facility on [DATE]. Resident #1's was diagnosed with essential (primary) hypertension, type 2 diabetes mellitus without complications, cerebral infarction, unspecified, spinal stenosis (space inside the backbone is too small placing pressure on the spinal cord and nerves), site unspecified, muscle weakness (generalized), unspecified atrial fibrillation (irregular heart beat), benign prostatic hyperplasia with lower urinary…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in 1.The facility failed to ensure that ice scoops will be cleaned and stored in a separate container that limits cross-contamination. 2.The facility failed to ensure that all cold and dry goods items will be stored 6 inches above the floor. These failures could place residents at risk of foodborne illness and disease. Findings included: 1. Observation on 7/13/23 at 8:30 AM with Dietary A revealed that the ice scoop was left in the ice bin on top of the ice. 2. Observation on 7/13/23 at 9:00 AM with the Dining Services Director revealed that dry goods and cold foods were stored 4 inches above the floor. Interview with the Dining Services Director on 7/13/23 at 9:20 AM revealed the ice scoop should not be left in the ice bin. Interview with the Dining Services Director on 7/13/23 at 9:25 AM revealed that dry goods and cold foods will be appropriately…

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 person-centered care plans for each resident's services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 21 residents (Resident #86) reviewed for the develop and implement comprehensive care plans. - The facility failed to ensure Resident #86's comprehensive care plan included the care for her schizoaffective and delusional diagnoses. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. Findings included: Record review of Resident #86's face sheet undated revealed an [AGE] year-old female who admitted into the facility on [DATE]. The resident was diagnosed with schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder such as depression or bipolar disorder), delusional disorder (is a…

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 garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 07-13-23 at 8:55 am, with the Dining Services Director revealed the facility's dumpster area,was not in use when it was observed to be open which was in the lot behind the dietary department had a commercial -size dumpster and the lid and door were opened. Interview on 07-13-23 at 9:00 am, with the Dining Services Director she stated the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. Record review of the facility policy and procedure of Dispose of Garbage and Refuse dated 8/2017 read in part. All garbage and refuse will be collected and disposed of in a safe and efficient manner. 2. The Dining Services Director will ensure that: appropriate lid and door…

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.