Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review the facility failed make sure that drugs were stored
properly and only authorized persons had access to one of two carts reviewed for drug storage and labeling
on Hall A 3rd floor.The facility failed to ensure the 3rd floor Hall A medication cart was locked and
medications were secured and not accessible to other staff, residents, or visitors.This failure could place
residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or
missing medications.Findings Included:Observation of 3rd floor Hall A medication cart on 11/25/2025 at
3:29 PM revealed it was unattended and locked with each drawer opening when pulled. LVN A was seated
at the nurse's station and was ask to review the cart. The medication cart was up against the wall in the 3rd
floor Hall A corridor. The locking mechanism was pushed in signifying a locked position and was not
secured with each drawer opening when pulled. The cart contained prescribed medication for residents and
over the counter medications. LVN A walked to the cart from the nurse's station and pulled on each drawer
which opened.Interview and observation on 11/25/2025 at 3:30 PM revealed LVN A had worked at the
facility since May of 2025. She revealed she did not understand why the cart was locked and the drawers
could be opened. LVN A took the action of unlocking the exterior cart lock, opening and closing each
drawer one at a time to ensure that each one was fully closed, and re-locking the cart. She said she was
responsible for ensuring the medication cart was locked. She said if a medication cart was left unlocked
and unattended then medications could go missing by a resident, family member, and staff. She said this
could lead to an overdose. She revealed that one drawer could have been slightly ajar causing the lock to
not engage and secure the medications on the cart.An interview with the ADON A on 11/26/2025 at 03:25
PM revealed she had worked at the facility since June of 2025. She said that a resident with dementia could
take a medication that they should not take if the medication cart was left unattended and unlocked. She
revealed that someone accessing the cart could have an allergy from using a medication that was not
prescribed for them. She revealed that the unattended and unlocked cart could lead to drug diversion.An
interview with the DON on 11/26/2025 at 3:45 PM revealed that the concern with an unsecured cart that is
left unattended was that residents could take medication that they are not supposed to take.Record review
of Medication Administration: Medication Carts and Supplies for Administering Medication Policy revised
05/2007 revealed:Policy: It is the policy of the facility to store all drugs and biologicals in locked
compartments under proper temperature controls. The medication supply is accessible only to licensed
nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. Procedure:
Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications
(e.g. medication aides) are allowed access to medications. Medication rooms, carts, and medication
supplies are locked or attended by persons with authorized access.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
675509
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
11/26/2025
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record reviews, the facility failed to maintain medical records that were
complete and accurately documented for 3 of 3 residents (Resident #1, Resident #2, Resident #3) reviewed
during the complaint investigation. The facility failed to ensure that Resident #1's treatment administration
record noted treatments on 9.6.2025, 9.20.2025, 10.2.2025, 10.25.2025 as required by the orders noted on
the electronic medical record. The facility failed to ensure that Resident #2's treatment administration record
noted treatments on 9.2.2025, 11.5.2025 as required by the orders noted on the electronic medical record.
The facility failed to ensure that Resident #3's treatment administration record noted treatments on
10.3.2025, 10.10.2025, 10.15.2025, 10.26.2025, 11.2.2025 as required by the orders noted on the
electronic medical record. This failure could place residents at risk of not receiving necessary care and
services daily as ordered by the physician to promote proper healing of active wounds.Findings include:
During an observation and interview on 11.25.2025 at 4:20 PM, Resident #1 was observed seated in his
wheelchair with his left foot bandaged at the ankle. He stated that he was receiving treatment for two
wounds. The other wound was on his left buttock.Record review of Resident #1's admission record, dated
11.25.2025, reflected a [AGE] year-old male who was readmitted to the facility on 2.17.2025 with diagnoses
of type 2 diabetes (a chronic condition that affects the way the body metabolizes sugar leading to high
blood sugar levels) with foot ulcer (open wound), unspecified cirrhosis (inflammation and scaring) of the
liver, other peripheral vascular (affects the blood vessels) diseases, stage 4 pressure ulcer (open wound) of
left buttock, stage 4 pressure ulcer (open wound) of left ankle, non-pressure chronic ulcer(open wound) of
unspecified part of left lower leg limited to breakdown of skin, and cellulitis (bacterial skin infection) of left
lower limb.Record review of Resident #1's MDS assessment completed on 9.1.2025 revealed a BIMS score
of 15 which indicated no significant cognitive impairment. Resident #1 was coded as receiving skin and
ulcer/injury treatments for stage 4 pressure ulcers. Resident #1 was coded as using a motorized wheelchair
to ambulate. Record review of Resident #1's Comprehensive Care Plan, dated 4.14.2025, reflected venous
ulcer to the left ankle related to diabetes, vascular insufficiency, poor glycemic control, non-compliance with
diet, and edema requiring wound monitoring and treatment. Record review of Resident #1's TAR record for
September of 2025 and October of 2025 revealed that wound care for the left ankle was to be performed
once a day with an order start date of 8.14.2025. Wound care for the lower left buttocks was to be
performed once a day with an order start date of 8.27.2025. Record review of Resident #1's TAR record for
the month of September and October revealed staff had failed to mark completion of wound care treatment
on 9.6.2025, 9.20.2025, 10.2.2025, and 10.25.2025 as required by the orders noted on the electronic
medical record.Record review of Resident #2 admission Record revealed that the resident was discharged
from the facility on 11.18.2025 to an acute care hospital.Record review of Resident #2's admission record,
dated 11.25.2025, reflected an [AGE] year-old female who was readmitted to the facility on 11.02.2025 with
diagnoses of unstageable pressure ulcer (open wound) of the sacral (triangular bone at the base of the
spine) region, chronic obstructive pulmonary (lung) disease, morbid obesity (over weight), diabetes mellitus
2 (a chronic condition that affects the way the body metabolizes sugar leading to high blood sugar levels),
unspecified severe calorie malnutrition, and chronic respiratory failure with hypoxia (low levels of oxygen in
body tissue).Record review of Resident #2's MDS assessment completed on 11.13.2025 revealed a BIMS
score of 3 which indicated severe cognitive impairment. Resident #1 was coded as dependent where a
helper does all the effort for mobility in bed and transfers out
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675509
If continuation sheet
Page 2 of 4
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
11/26/2025
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
of bed and self-care needs. The resident was always incontinent. The resident was coded as having an
unstageable pressure ulcer requiring ulcer/injury care. Record review of Resident #2's Comprehensive
Care Plan, dated 9.1.2025, reflected the resident has a stage IV pressure ulcer requiring wound vac,
wound treatments, wound monitoring, turning, repositioning, enhanced barrier precautions, and a low air
loss mattress. Record review of Resident #2's TAR record for the month of September 2025 and November
2025 revealed that wound care for the sacrum was to be performed once a day with an order start date of
9.1.2025. Record review of Resident #2's TAR record for the month of September and October revealed
staff had failed to mark completion of wound care treatment on 9.2.202 and 11.5.2025 as required by the
orders noted on the electronic medical record. During an observation and interview on 11.25.2025 at 5:00
PM, Resident #3 was observed lying in bed with a boot on his left foot. He stated that he had one small
wound. He said he was supposed to receive wound care every day for his heel, but he believed that some
treatments were skipped.Record review of Resident #3's admission record, dated 9.19.2025, reflected a
[AGE] year-old male with diagnoses of diabetes mellitus 2 (a chronic condition that affects the way the body
metabolizes sugar leading to high blood sugar levels), methicillin (drug) resistant staphylococcus aureus
infection, anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's
tissues), and end stage renal (kidney) disease.Record review of Resident #3's MDS assessment completed
on 9.30.2025 revealed a BIMS score of 15 which indicated no significant cognitive impairment. Resident #1
was coded as requiring partial to substantial assistance with mobility. He ambulated with a walker. He was
at risk and being treated for an unstageable deep tissue injury and a stage 2 pressure ulcer. Record review
of Resident #3's Comprehensive Care Plan, dated 9.21.2025, reflected a below knee amputation required
enhanced barrier precautions, monitoring, supplements, and wound treatment. A deep tissue injury to his
left heel required enhanced barrier precautions, monitoring, administration of medications as ordered, heel
protectors, and repositioning. Record review of Resident #3's TAR record for the month of October 2025
and November 2025 revealed that wound care for the left heel was to be performed once a day with an
order start date of 9.23.2025. Wound care for the right buttocks was to be performed once a day with an
order start date of 9.22.2025. Wound care for a right leg below knee amputation was to be performed once
a day with an order start date of 9.21.2025. Record review of Resident #3's TAR record for the month of
September and October revealed staff had failed to mark completion of wound care treatments on
10.3.2025, 10.10.2025, 10.15.2025, 10.26.2025, and 11.2.2025 as required by the orders noted on the
electronic medical record. During an interview on 11.26.25 at 2:48 PM, LVN B revealed that the TAR
records for Residents #, #2, and #3 were not marked as completed on 9.2.2025, 9.6.2025, 9.20.2025,
10.2.2025, 10.3.2025, 10.10.2025, 10.15.2025, 10.25.2025,10.26.2025, 11.2.2025, and 11.5.2025. She
stated that she was the wound care nurse for the facility and that RN C assisted as needed and on
weekends. She revealed that the reasons nothing was marked on the TAR could include: the treatment
being marked on another line of the TAR, an EMR glitch, or the treatment may not have been done or
recorded. LVN B stated that the TAR was the only record where treatment completion was recorded. She
revealed that the impact to the resident of a missed treatment depended on the resident, but a missed
treatment could not allow healing to occur. During an interview on 11.26.25 at 3:25 PM, the ADON revealed
that the TAR records for Residents #, #2, and #3 were not marked as completed on 9.2.2025, 9.6.2025,
9.20.2025, 10.2.2025, 10.3.2025, 10.10.2025, 10.15.2025, 10.25.2025,10.26.2025, 11.2.2025, and
11.5.2025. She stated that a blank on the TAR meant that it was not marked off. She revealed that the only
way to determine if the treatment was completed was to ask the nurse working that shift. She revealed that
missing a treatment could impact the resident by making the wound worse. She
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675509
If continuation sheet
Page 3 of 4
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
11/26/2025
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
revealed that wound care treatment should be done unless the resident refuses it or there is another
reason not to complete it. During an interview on 11.26.25 at 3:45 PM, the DON revealed that the TAR
records for Residents #, #2, and #3 were not marked as completed on 9.2.2025, 9.6.2025, 9.20.2025,
10.2.2025, 10.3.2025, 10.10.2025, 10.15.2025, 10.25.2025,10.26.2025, 11.2.2025, and 11.5.2025. She
revealed that a blank meant that the nurse did not document a resident's refusal and she would have to
interview the nurse to determine if the treatment was provided. She said that implications for not marking
the treatment as completed was progression of the wound that might not heal. She stated that it depends
on other factors like medication, diet, and treatment plan. It all goes together.
Event ID:
Facility ID:
675509
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the November 26, 2025 survey of Parklane West Healthcare Center?
This was a inspection survey of Parklane West Healthcare Center on November 26, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Parklane West Healthcare Center on November 26, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional princip..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.