Inspection·April 25, 2025

F 0805 Level of Harm - Minimal harm or potential for actual harm A record review of Resident #1's medical records from 1/2/2025 to 4/25/2025 revealed Resident #1 had triggered for weight loss as documented by the physician's order dated 1/2/2025 for a FMP however, Resident #1 was assessed by the RD on 1/15/2025 to weight 122.1 lbs. with a BMI of 27.4 which indicated her to be 20% overweight for her height. Further review revealed Resident #1 had no further weight loss throughout the period reviewed. Residents Affected - Some During an observation on 4/24/2025 at 8:30 AM revealed Resident #1 seated in the dining room eating her breakfast. The breakfast served was pancakes served with sugar free syrup, bacon, oatmeal, coffee, and juice. During an interview on 4/24/2025 at 8:33 LVN A stated she had reviewed Resident #1's physician's orders and recognized Resident #1 was prescribed by the physician to receive a FMP, however her meal ticket did not reflect the FMP order. LVN A stated the meal ticket guides staff as to what to serve residents. LVN A stated she had reviewed Resident #1's meal ticket prior to serving Resident #1 her breakfast and did not recognize from the meal ticket Resident #1 was to be served a FMP meal. During an interview on 4/24/2025 at 8:40 AM the ADON stated she reviewed Resident #1's physician's order which included a fortified meal plan. The ADON stated the FMP would alert the nurses who would review the meal prior to serving the meal to review the meal for extra calories such as extra servings of fats and carbohydrates, butter, and breads. The ADON stated if the meal ticket did not state FMP then the staff would not know the resident needed to be served a FMP meal. The ADON stated the process would be for the nursing staff to communicate the FMP order to the dietary manager. The ADON stated she reviewed Resident #1's weight status and Resident #1 has gained and maintained her weight since January 2025 and the nursing staff and cooperating registered dietician had been having the nursing staff administer extra calories during Resident #1's medication administration. During an interview on 4/24/2025 at 8:50 AM the Food Service Manager (FSM) stated he had received communication from the nursing department that Resident #1 was prescribed a FMP. The FSM stated a FMP consisted of serving the meal as approved by the registered dietician and to the add extra calories, fats, and carbohydrates to the resident's meal; for example, extra butter, and extra bread, and gravy. The FSM stated he reviewed the dietary resident database and recognized Resident #1's was documented as needing a FMP and could not explain why her meal ticket would print out without the direction for the FMP. The FSM stated the meal tickets would be printed out prior to the serving of the meals and would guide the cook as how to plate the meal and in this case to serve extra calories to the meal, without the FMP on the ticket my staff would not know to add extras. During an interview on 4/25/2025 at 11:00 AM the DON stated her expectation was for the FSM to accurately serve the residents meals per the physician and nursing dietary communications and for the staff to review the residents' meal tickets to their orders after there was a change in the resident's meal plan. The DON stated the risk to residents was they may not have received their meal as prescribed by the physician. A record review of the facility's Dietary Services Meals and Food policy dated 6/2027, revealed, It is the policy of this facility to ensure dietary services are provided to our residents operating within the confines of Texas state regulations. PROCEDURE: I. A dietary manager is responsible for the total food service of this facility . 5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675509 If continuation sheet Page 2 of 3 Printed: 05/15/2026 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 675509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parklane West Healthcare Center 2 Towers Park LN San Antonio, TX 78209 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 0805 Therapeutic diets as ordered by the resident's physician are provided according to the service plan Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675509 If continuation sheet Page 3 of 3