Azria Health Park Place

Inspectors wroteBased on clinical record review, hospitalization record review, facility policy review, resident and staff interviews, the facility failed to safely discharge 1 of 3 residents (Resident #1) reviewed for discharge planning, by discharging the resident to a location that did not meet his health and safety needs. On 4/21/26, Resident #1 with a history of a traumatic brain injury and cognitive impairment was assisted by nursing staff to sign an Against Medical Advice form after the resident became upset when reminded of the facility smoking policy and stated he would just leave. Resident #1 signed the AMA form, took his belongings and left the facility via a cab. Resident #1 went to a homeless shelter without his medication and was unable to tell the shelter staff where he came from or how he arrived at the shelter. [...]

Inspectors wroteBased on observation, record review, staff interviews and policy review, the facility failed to ensure residents on a therapeutic diet to include pureed food (Residents #24, #38, #40 and #42) were served the correct amount and serving size. The facility reported a census of 51 residents.

Inspectors wroteBased on observations, staff interview and policy review, the facility failed to ensure staff used proper food handling procedures, failed to ensure hair was covered by staff while in the kitchen area, failed to maintain a clean kitchen area where food was served to residents, failed to ensure all food was covered on room trays and failed to ensure staff used proper hand placement on glassware used to serve residents. The facility failed to prevent possible contamination of food. The facility reported a census of 51 residents.

Inspectors wroteBased on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past 3 surveys, and staff interview, the facility failed to correct their own deficiencies for 1 of 1 areas of concern. The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, staff interview, guidance from the Centers for Disease Control (CDC) and facility policy review, the facility failed to offer the recommended pneumococcal and Influenza vaccines to eligible residents for 4 of 5 residents reviewed for vaccines (Resident #14, Resident #33, Resident #41 and Resident #50). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review, the facility failed to limit a as needed (PRN) psychotropic drug (drugs that affect a person's mental state) to 14 days for 1 of 5 residents reviewed (Resident #21). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to refer a resident (Res #3) for a Level II PASRR evaluation following a newly diagnosed mental disorder for one of four residents reviewed for PASRR (Pre admission Screening and Resident Review). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review, the facility failed to fully submit a Level 1 Preadmission Screening and Resident Review (PASRR) evaluation to the appropriate state-designated authority prior to admission or within 30 days for 1 of 4 residents reviewed (Resident #50). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, staff interview, and contracted Registered Dietitian interview, the facility failed to implement dietary interventions in a timely manner for a resident who was experiencing significant weight loss (Res # 44). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to perform pre and post dialysis assessments for one of one resident reviewed for dialysis (Res #6). The facility reported a census of 51.

Inspectors wroteBased on clinical record review, staff interview and policy review, the facility failed to follow through and act on recommendations of Pharmacy drug regimen reviews to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for 1 of 5 residents reviewed (Resident #21). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, staff interview, guidance from the Centers for Disease Control (CDC) and facility policy review, the facility failed to offer the recommended COVID-19 vaccine to eligible residents for 3 of 5 residents reviewed for vaccines (Resident #14, Resident #41 and Resident #50). The facility reported a census of 51 residents.

Inspectors wroteBased on direct observation, clinical record review, resident and staff interview, and facility policy review, the facility failed to maintain the kitchen in a safe and hygienic manner that is free from pests and protects food safety and prevents food borne illness. It further failed to maintain regular kitchen and dietary cleaning logs to maintain and ensure cleanliness in the kitchen. The facility reported a census of 59. The Stage Agency informed the facility of the Immediate Jeopardy (IJ) on 09/03/2025 at 03:55 PM. The IJ began on at least 04/29/2025. Facility Staff removed the Immediate Jeopardy on 09/04/2025. The facility staff removed the IJ by implementing the following actions:1. Facility ceased operations of food service from the kitchen on 9/3/25 at 3:55pm. Facility will order outside meals, and ensure diet orders are followed.2. [...]

Inspectors wroteBased on observations, resident and staff interviews, and policy review, the facility failed to provide a clean, comfortable and homelike environment. The facility also failed to maintain and ensure adequate supplies of the appropriate sized briefs to meet the needs of all residents who used briefs and pull-ups, and failed to ensure an adequate supply of resident care supplies and linens for two of two units. The facility identified a census of 59 residents.

Inspectors wroteBased on observations, record review, resident and staff interviews, call light reports, resident council meeting notes, and policy review the facility failed to provide sufficient staff to meet resident needs with toileting assistance and answering call lights (within 15 minutes) for 2 of 2 units. The facility reported a census of 59 residents.

Inspectors wroteBased on observations, resident, and staff interviews, Centers for Disease Control (CDC) website data, and resident council meeting notes the leadership of the facility failed to provide adequate management of the facility. The Administrative team failed to provide adequate incontinent supplies, linen supplies and a comfortable homelike environment free of vermin. In addition, the facility failed to provide the residents with a clean kitchen. The facility identified a census of 59 residents.

Inspectors wroteBased on review of Certification and Survey Provider Enhanced Report (CASPER) from the Centers for Medicare & Medicaid Services (CMS), staff interview, and review of the facility QAPI (Quality Assurance Performance Improvement) plan, the facility failed to ensure an effective process to address previously identified quality deficiencies. The facility reported a census of 59 residents. Findings Include:The CASPER Report for the facility identified the facility had previously received an Infection control deficiency in 2023 and 2024. A Safe, clean, and homelike environment deficiency in 2023 and 2024. At the conclusion of the complaints survey on 09/11/2025 the facility was cited again for Infection control and Homelike environment. The Facility's QAPI Plan, revised 2/05/2025, identified a monitoring process which included multiple sources of data. [...]

Inspectors wroteBased on direct observation, clinical record review, resident and staff interview, and facility policy review, the facility failed to provide incontinence care and transfers in a manner that promotes hygiene and protects residents from the spread of disease when they failed to change contaminated gloves and used another residents mechanical lift sling without sanitizing it first for 3 of 4 residents reviewed. (Resident #1, #8, and #12). In addition, the facility failed to utilize Enhanced Barrier Precautions (EBP) when providing care to a resident with an indwelling catheter (Resident #8). The facility reported a census of 59.

Inspectors wroteBased on observation, resident and staff interviews, manufacturer instructions, and policy review the facility failed to lock brakes on a bed when staff repositioned and provided cares for 1 of 3 residents observed (Resident #12), and failed to operate a mechanical lift safely for 2 of 3 residents observed for transfers (Resident #12 and #1). The facility reported a census 59 residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure a homelike environment and reduce clutter in the hallway for 2 or 2 units (North and South Halls). The facility reported a census of 49 residents.

Inspectors wroteBased on observations, staff interviews and facility policy review the facility failed to store and serve food in a sanitary manner. The facility reported a census of 49 residents.

Inspectors wroteBased on record review, facility investigation file review, resident and staff interviews, and facility policy review, the facility failed to ensure all allegations of abuse including allegations of staff to resident verbal threats and rough treatment, and inappropriate touching of a resident's buttocks by Staff A were reported timely to the facility administration for three of four residents reviewed for abuse (Resident #10, #38, and #28). The incident of alleged abuse that occurred on 8/8/24 was not reported to the Department of Inspections, and Appeals and Licensing (DIAL) until 8/30/24. The allegation of abuse on 10/21/24 was not reported to DIAL until 10/23/24. The facility reported a census of 49 residents.

Inspectors wrote2. A Past Calls report dated 9/20/24 to 11/19/24 revealed call light response greater than 15 minutes for the following: a. Room North (N) 10: 9/20 - 9/30/24: 16 times, with the longest response time 2 hours and 33 minutes 10/1 - 10/31/24: 35 times, with the longest response time 2 hours and 12 minutes 11/1 - 11/18/24: 5 times, with the longest response time 33 minutes The majority of call light response times greater than 15 minutes occurred on the evening (2 PM - 10 PM) and night (10 PM - 6 AM) shifts. b. Room N20 9/20 -9/30/24: 6 times with the longest response time 2 hours and 17 minutes 10/1 - 10/31/24: 42 times with the longest response time 3 hours and 3 minutes 11/1 - 11/18/24: 17 times with the longest response time 1 hour and 1 minute. The majority of call light response times greater than 15 minutes occurred on the night (10 PM - 6 AM) and evening (2 PM - 10 PM) shifts. [...]

Inspectors wroteBased on facility record review, staff interview, and policy review, the facility failed to provide three of three sampled residents the required properly filled out forms for Medicare Liability Notices and Beneficiary Appeals within 48 hours of when skilled services ending (Resident # 26, # 204, # 205). The facility reported a census of 49 residents.

Inspectors wroteBased on record review, staff interviews and facility policy review the facility failed to accurately complete 1 of 30 resident's (Resident #47) MDS assessment tools. The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, facility policy, and staff interview, the facility failed to submit a new preadmission screening and resident review (PASRR) level 1 screening as required for 1 of 20 residents screened (Resident #32). The facility reported a census of 49.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility failed to track and document behaviors for residents taking psychiatric medication for 3 of 3 residents screened (Resident #32, #11, and #24). The facility reported a census of 49.

Inspectors wroteBased on clinical record review, observation, staff interview and manufacturer's instructions, the facility failed to administer insulin flexpen to ensure the proper amount of insulin administered for one resident observed who received insulin during medication pass (Resident #28). The facility reported a census of 49 residents.

Inspectors wroteBased on observations, resident and staff interviews, record review, facility policy and procedure, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers from developing on residents with history of pressure ulcers for two of two residents reviewed (Resident #1 and #2). The facility reported a census of 48 residents.

Inspectors wroteBased on observations, environmental tour, resident, staff and laundry personnel interviews, the facility failed to provide clean, available linen draw-pads for resident care and failed to keep a clean, safe, and comfortable homelike environment. The facility reported a census of 48 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and facility policy and procedure review, the facility failed to give medications as directed per the physicians orders during medication pass for (Resident #13), and failed to draw labs as ordered for (Resident #7) failed to follow physician orders for 3 of 3 residents reviewed (Resident #16, #19, and #20). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, and staff interview, the facility failed to maintain accurate resident records for 4 of 4 residents reviewed, (Resident #7, #16, #19 and #20). The facility census was 48 residents.

Inspectors wroteBased on clinical record review, resident and staff interview along with facility policy and procedure the facility failed to treat residents with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 2 out of 5 resident reviewed. (Resident #6 and #17). The facility identified a census of 48 residents.

Inspectors wroteBased on observations, resident and staff interview, clinical record review and policy review the facility failed to provide appropriate incontinence care by failing to ensure all stool was removed from the resident's skin for 1 of 1 resident reviewed (Resident #8) and failed to assist a resident with incontinency (Resident #6) and failed to assist a resident with supervision at meals (Resident #15). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, clinical record review, staff and resident interview at the time of the investigation, the facility failed to promptly identify and intervene for two residents that were at risk for pressure ulcers for 2 of 2 residents reviewed. (Resident #1 and #2). The facility identified a census of 48 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure a door was alarmed in the basement for which one (1) resident who was seen getting onto the elevator with staff supervision and went down to the basement (Resident #16) and failed to supervise two (2) residents who were not suppose to be in left in rooms unsupervised (Resident #15 and #16) and also failed to keep medication carts locked at all times on two (2) incidents. The facility census was 48 residents.

Inspectors wroteBased on record review, staff interview and facility policy the facility failed to have 1 of 3 residents seen at least once every 60 days by the physician. (Resident #6) The facility census was 48 residents.

Inspectors wroteBased on resident and staff interviews, along with the facility policy, the facility staff failed to answer resident call lights in a timely manner (no longer than 15 minutes) for 3 of 3 residents reviewed . (Resident #2, #14 and #15). The facility identified a census of 48 residents.

Inspectors wroteBased on observations, staff interview, clinical record review and policy review the facility failed to provide appropriate catheter care to prevent urinary tract infections for 1 of 1 residents reviewed (Resident #8) and failed to provide hand hygiene supplies to prevent cross contamination for 3 of 3 residents (#8, #9, and #10). The facility reported a census of 48 residents.

Inspectors wroteBased on policy review, document review, and staff interview the facility failed to implement the abuse and neglect policy by not completing background checks prior to staff employment. The facility reported a census of 49 residents.

Inspectors wroteBased on policy review, observation, document review, and staff interview the facility failed to make nursing staff information readily available in a readable format to residents and visitors at any given time. The facility failed to post the nurse staffing data. The facility reported a census of 49 residents.

Inspectors wroteBased on record review, policy review, and staff interviews the facility failed to complete Monthly Medication Regimen Review (MRR) by a licensed pharmacist for 4 of 5 residents reviewed (#14, #18, #31, & #37). The facility reported a census of 49.

Inspectors wroteBased on observation, document review, staff interview, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs by use of incorrect serving size portions for meals for 18 of 49 residents reviewed. The facility reported a census of 49 residents.

Inspectors wroteBased on document review and staff interview the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager. The facility reported a census of 49 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not labeling foods that were open with open dates, did not maintain chemical solution at the correct concentration in a low temperature dish machine, ensure kitchen staff wear hair restraints appropriately, and did not practice appropriate hand hygiene by touching food and contaminated objects. The facility reported a census of 49 residents.

Inspectors wroteBased on observation, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing catheter cares, enteral tube feedings, wound care and personal care for residents, and failed to review the infection control policy annually with appropriate staff. The facility reported a census of 49 residents.

Inspectors wroteBased on policy review, document review, and staff interview the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property when 3 employees reviewed did not have current training for Dependent Adult Abuse. The facility reported a census of 49 residents.

Inspectors wroteBased on policy review, document review, and staff interview the facility failed to ensure continued competence of nurse aides by failing to provide the required in-service training at a minimum of 12 hours per year for 5 of 5 employees reviewed. The facility reported a census of 49 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to complete activities of daily living on a resident requiring assistance with gown change and hygiene. The facility further failed to provide privacy to a resident requiring enteral feeding for 2 of 8 residents reviewed (Residents #21 & #32).

Inspectors wroteBased on observations, resident and staff interviews and the facility policy review, the facility failed to keep a clean, safe, and comfortable homelike environment. The facility reported a census of 49 residents.

Inspectors wroteBased on record review, policy review, and staff interview the facility failed to notify the Long-Term Care Ombudsman of a transfer to the hospital for 2 of 3 residents reviewed (Resident #24, and #34). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to obtain bed hold notifications for 2 of 2 residents reviewed (Residents #24, #34). The facility reported a census of 49 residents. Findings Include: 1. Review of Resident #24's Minimum Data Set (MDS) dated [DATE] revealed a most recent admit date from an acute hospital stay dated 4/13/23. Review of Resident #24's Electronic Health Record (EHR) revealed that Resident #24 was hospitalized from [DATE] through 4/13/23. 2. Review of Resident #34's MDS dated [DATE] revealed a most recent admit date from an acute hospital stay dated 6/2/23. Review of Resident #34's EHR revealed that Resident #34 was hospitalized from [DATE] through 6/2/23. During an Interview 11/15/23 at 10:54 AM with Staff A and the Administrator revealed the facility did not have bed hold notifications for these hospitalizations. [...]

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to implement a comprehensive care plan for 3 of 3 residents reviewed (Residents #1, #4, & #25). The facility reported a census of 49 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to provide staff assistance for activities of daily living by not offering an opportunity to complete oral hygiene for 1 of 4 residents reviewed (Residents #29). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical document review, staff interview, and policy review the facility failed to provide needed services in accordance with professional standards by not providing medical services related to inadequate dental health and by not following physicians orders for 2 of 2 residents reviewed (Resident #34 & Resident #4). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, resident and staff interview, and policy review, the facility failed to provide restorative services to prevent decline in range of motion and mobility for 2 of 2 resident (Resident #1 & #25). The facility reported a census of 49.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by not applying initials to formula bottles. The facility further failed to verify the gastrostomy tube (feeding tube) was functioning properly before beginning a feeding for 3 of 3 residents reviewed (Resident #21, #45, and #47). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to complete pre and post dialysis assessments for 1 of 1 resident reviewed for dialysis treatment (#25). The facility reported a census of 49 residents.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to respond to residents' call light within 15 minutes for 2 residents reviewed (Residents #14 & #28). The facility reported a census of 49.

Inspectors wroteBased on clinical record review, policy review, and staff interviews the facility failed to implement gradual dose reductions (GDR) instead continued psychotropic medications without review and failed to ensure as needed (PRN) orders for psychotropic medications did not exceed 14 days without physician review for 1 of 5 residents reviewed (Resident #34). The facility reported a census of 49 residents.

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to keep all medications in a locked medication cart, inaccessible to unauthorized staff and residents. The facility reported a census of 49 residents.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and policy review the facility failed to provide needed assistance in making appointments for dental services for 1 of 1 residents (Resident #34). The facility reported a census of 49 residents.

Inspectors wroteBased on observations, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 3 of 8 residents reviewed (Residents #6, #32, and #34) The facility reported a census of 49 residents.

Inspectors wroteBased on staff interviews and facility policy review the facility failed to produce Quality Assurance Performance Improvement (QAPI) documentation that demonstrated the implementation and effectiveness of a comprehensive QAPI program that addressed the full range of services the facility provided. The facility reported a census of 49 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to have an Infection Preventionist in attendance during the facilities quarterly meetings from December 2022 to November 2023 for 2 out of 4 quarters. The facility reported a census of 49 residents.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure the resident call system functioned properly for 1 of 1 resident (Resident #14). The facility reported a census of 49.