Park Place Nursing & Rehabilitation Center

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

understood, usually understood others, he had a BIMS of 2 out of 15 indicating he had severely impaired cognition, and he had no behaviors.Record review of the care plan revised on 08/12/25 indicated Resident #2 had no indication of behaviors.Record review of Nurse Notes for Resident #2 indicated on 05/02/25 [Resident #2] was sitting at the front door when another resident attempted to help him to the dining room for dinner. [Resident #2] then scratched and bit the female resident attempting to help him. received orders to send the resident to the emergency room due to him being a harm to others. The resident's mother was notified. EMS notified. [Resident #2] left the facility via EMS stretcher. The note was signed by RN Record

review of an Incident/Accident Report dated 05/02/25 indicated Resident #2 .[Resident #2] was sitting at

the front door when another resident attempted to help him to the dining room for dinner. [Resident #2] then scratched and bit the female resident attempting to help him. This RN notified NP and received orders to send the resident to the emergency room due to him being a harm to others. The resident's mother was notified. EMS notified. Resident left the facility via EMS stretcher.[Resident #2] was transferred to the ER for evaluation due to behaviors and change in baseline; returned with new orders for [antibiotic] related to positive urine culture.During an observation and interview on 11/19/25 at 10:45 a.m. Resident #2 was in propelling himself in the main area of the facility. Interactions with other residents were appropriate.

Resident #2 indicated he was doing okay and had no issues with anyone. During an interview on 11/20/25 at 07:30 a.m. RN B said Resident #2 would have times he refused care, but he had not attacked another resident like he did Resident #1. She said she had no issues with him behaving like that again. She said Resident #1 and Resident #2 used to sit at the same table in the dining room but they don't since he grabbed her by the shirt and bit her back in May. She said they avoid each other. During an interview on 11/19/2025 at 3:30 p.m., the DON said Resident #2 had not had behaviors of grabbing or biting other residents. He was known to bite himself at times. She said Resident #1 and Resident #2 were separated immediately after he grabbed her shirt and bit her hand. She said assessments were done on both residents which indicated Resident #1 had red areas to her chest and a bite mark on the back side of her left hand and Resident #2 had no injuries. Resident #2 was sent out to the hospital for evaluation of his aggressive behavior. Record review of a Provider Investigation Report dated 05/07/25 indicated an incident categorized as Other: Resident to Resident Altercation occurred on 05/02/25. The incident involved Resident #1 and Resident #2. At approximately 6:05 a disturbance was heard coming from the entrance/lobby area of the facility by staff serving dinner in the main dining room. Upon arrival staff found Resident #1 was pressing her hand against her chest and standing a few feet away from Resident #2 who was seated in his wheelchair. Staff immediately separated the Residents and initiated assessments to determine if either of them were injured from the altercation. Resident #2 was transported to the hospital for evaluation of aggressive behavior and potential underlying medical conditions. An assessment conducted by RN B determined Resident #2 had no injuries from the altercation. He left the facility via EMS transport.

RN B assessed Resident #1 and noted red areas to her chest and the left hand and area above left thumb were noted to be red without any broken skin.Record review of the Abuse, Neglect, Exploitation, and Misappropriation of Property policy revised February 12, 2020 indicated the following: .Policy 1. Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Place Nursing & Rehabilitation Center

2450 E Fifth St Tyler, TX 75701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

requested the bedpan at shift change and the outgoing staff checked on him prior to leaving the shift but he was not finished, so he had to wait a little longer for oncoming staff to remove him from the bedpan. She said he denied abuse and said he felt safe at the facility. She said he was apprehensive about his upcoming discharge and providing self-care at home. She said allegations of abuse should be reported to the Administrator/abuse coordinator immediately, so the appropriate authorities (local police, state agencies, ombudsman, family) could be notified during the required timeframe. During an interview on 11/19/2025 at 4:00 p.m., the Administrator said that he received an electronic message from PTA J that Resident #6 had made a statement regarding being abused. He said he and the DON immediately went to interview Resident #6. He said that Resident #6 declined being abused and acknowledged he was frustrated because of loss of independence. He said Resident #6 said he had requested the bedpan at shift change and the outgoing staff checked on him prior to leaving the shift but he was not finished, so he had to wait a little longer for oncoming staff to remove him from the bedpan. He said Resident #6 denied abuse and said

he felt safe at the facility. He said he did not report the allegation of abuse because during his 2-hour window he spoke with the resident, and he denied the allegation. He said if abuse occurred that he would have reported it to the appropriate authorities (local police, state agencies, ombudsman, family) during the required timeframe. He acknowledged that his policy does say that alleged abuse should be reported to the state agency within 2 hours and he should have reported the allegation to the state agency within 2 hours.

Record review of the facility's Abuse investigating and reporting policy revised July 2017 indicated .

Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of property will be reported by the facility administrator or his or her designee to the following persons or agencies: a. The state licensing certification agency responsible for surveying licensing the facility. 2. An alleged violation of abuse neglect exploitation OR mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately but no later than: a. Two hours if the alleged violation involves abuse or has resulted in serious bodily injury.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Place Nursing & Rehabilitation Center

2450 E Fifth St Tyler, TX 75701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

conditions that damage blood vessels and block blood flow to your brain) and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of admission MDS assessment dated [DATE REDACTED] for Resident #12 indicated she was able to make herself understood and understood others, she was cognitively intact (BIMS score 13), she was at risk for developing pressure ulcers and was utilizing pressure reducing devices for bed and chair for skin ulcer and injury prevention.

She was frequently incontinent with bowel and bladder. Record review of a base line care plan dated [DATE REDACTED] for Resident #12 reflected it did not contain the following CMS guideline required information:*Precautionary plan for fall risk;*Dietary instructions for Diabetic diet;*Prescribed PRN (as needed) medications;*Prescribed routine medications;*Prescribed therapy services; and*Failed to provide Resident #12 with a summary of the baseline care plan.During an interview on [DATE REDACTED] at 2:15 p.m., LVN H said she completed the admission on Resident #12 on [DATE REDACTED] but did not have time to complete the nursing section of the baseline care plan. She said that during shift report she told the oncoming nurse that

the baseline care plan nursing section needed to be completed. Record review of a face sheet dated [DATE REDACTED] indicated Resident #15 as [AGE] year old female admitted on [DATE REDACTED], and her diagnoses included femur fracture (broken upper leg bone), delirium due to known physiological condition (serious disturbance

in mental abilities that results in confused thinking and reduced awareness of the environment) and hypertension (condition in which the force of the blood against the artery walls is too high).Record review of

a base line care plan dated [DATE REDACTED] for Resident #15 reflected it did not contain the following CMS guideline required information:*Dietary instructions for Regular diet;*Prescribed social services; and*Prescribed therapy services; and*Failed to provide Resident #15 and/or her representative with a summary of the baseline care plan.During an interview on [DATE REDACTED] at 4:15 p.m., SW said that she was unsure why Resident #15's social service base line care plan section (social services provided, mental health needs, behavioral concerns, PASARR Level recommendations, social service goals, and depression screening) was not completed. She said that as soon as she realized a new resident was admitted she completed the social service baseline this baseline care plan must have been missed.During an interview on [DATE REDACTED] at 10:39 a.m. the DON said the base line care plan was to be completed within 48 hours of admission and acknowledged by the resident or resident representative. She said she did not know why Resident #5, #12, and #15's baseline care plans were not completed on time. She said the admitting charge nurse was responsible for completing the nursing and diet information, social workers and therapy staff were responsible for their sections. She said the completed baseline care plan should be acknowledged by the resident or resident representative. She said not completing the baseline care plans within 48 hours could delay the residents immediately health and safety needs. Record review of a facility's Care Plans - Baseline policy revised on [DATE REDACTED] indicated .a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimal health care information necessary to properly care for their residents including but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. physician orders c. dietary orders; d. therapy services; e. social services; and f. PASARR recommendations, if applicable.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Place Nursing & Rehabilitation Center

2450 E Fifth St Tyler, TX 75701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

next due assessment. She said the residents were at risk of skin breakdowns or not receiving care as necessary without assessments. She said that the CNAs usually report to charge nurses if they identify any new skin issues during personal care or bath/showers. During an interview on 11/19/2025 at 5:15 p.m., the DON indicated that the charge nurses were responsible for completing the weekly skin assessments unless

the resident was being seen by the wound care nurse and wound care physician. The DON said the nurses were trained in how to document the weekly skin assessments in the new EMR. The DON said she had just learned from the facility staff that the EMR was not automatically generating some of the weekly skin assessments as required. She said that RN B told her that the weekly skin assessment was not generating weekly in the EMR if the previous weekly skin assessment was not completed. She said she had contacted

the EMR representative and submitted a ticket to attempt to alleviate this issue. She said the EMR should generate a weekly skin assessment weekly until the resident is discharged . She said that she will have staff do a sweep of all residents and conduct a skin assessment. She said she would start tracking the weekly skin assessments as facility had done previously by paper copy of list skin assessments required weekly assigned to charge nurse for each shift with room number and bed location. She said once the new WCN becomes more familiar with the facility and residents she will be assigned to complete the weekly skin assessments on the residents. The DON said skin assessments not being completed could cause residents to have skin impairment which may go untreated. The DON said that the CNAs are responsible for reporting any skin impairment identified while providing personal care and baths, so she would hope that no skin impairments go unidentified or untreated. Record review of the facility's Prevention of Pressure Injuries policy revised April 2020 indicated Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors . Risk Assessment. 1. Assess the resident on admission (within 8 hours) for existing pressure injury risk factors.

Repeat the risk assessment weekly and upon any changes in condition. Skin Assessment. 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment as indicated according to the resident's risk factor and prior to discharge. 2. During a skin assessment inspect. Presence of a. erythema (redness) b. temperature of skin and soft tissue; and c. edema (swelling) .

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Place Nursing & Rehabilitation Center

2450 E Fifth St Tyler, TX 75701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

medication aides to count the narcotics at shift change. She said she was not aware of all the missing signatures from the shift count sheets. She said they figured out where Resident #3's hydrocodone/acetaminophen 5mg/325mg missing tablet went. She said she spoke with Resident #3 and

she said she had received the medication when she requested it. She said LVN C was not able to be contacted at this time because she was asleep. During an interview on 11/20/25 at 10:28 a.m. the Administrator said staff were expected to count the narcotics at shift change. He said if they were not counted staff would be counseled and re-educated. He said there was the risk of drug diversion if not counted. Record review of a Controlled Substances policy dated 2001 indicated the following: Policy StatementThe facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976).Policy Interpretation and Implementation Handling Controlled Substances.4. If the count is correct an individual resident controlled substance record is made for each resident who will be receiving a controlled substance. Do not enter more than one (1) prescription per page. This record contains:. l. signature of nurse administering medication.Dispensing and Reconciling Controlled Substances.3. Nursing staff count controlled medication inventory at the end of each shift using these records to reconcile the inventory count.4. The nursing coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Event ID:

Facility ID:

If continuation sheet