Center at Park West LLC, the

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to:-Ensure food items in the main kitchen refrigerator were labeled and dated;-Maintain the ice scoop holder and the microwave in a sanitary condition; and, -Ensure raw meat was stored in a manner that prevented cross contamination of ready-to-eat foods.

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for two (#1 and #5) of six residents out of 17 sample residents. Specifically, the facility failed to:-Provide timely, consistent and effective monitoring and appropriate documentation for Resident #1's left lower leg amputation surgical incision, which resulted in the resident's transfer to the hospital where she was hospitalized for 10 days with a diagnosis of a left below the knee amputation incision infection; and,-Obtain wound care orders for Resident #5's skin tear in a timely manner. Resident #1 was admitted to the facility on [DATE] after a hospital stay for a surgical amputation of her left lower leg. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries to prevent or heal pressure injuries for two (#9 and #7) of six residents out of 17 sample residents. Specifically, the facility failed to:- Accurately identify, document, evaluate and monitor a pressure ulcer for Resident #9;- Ensure Resident #9's weekly skin assessments were documented thoroughly and accurately; and,- Ensure appropriate wound prevention interventions, including an air mattress, were implemented timely and consistently monitored for function and settings for Resident #9 and Resident #7. Resident #9, who was at risk for skin breakdown, was admitted to the facility on [DATE] following a hospitalization for a right hip fracture. [...]

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care for the resident that met professional standards of quality care for three (#2, #8 and #17) of five residents out of 17 sample residents. Specifically, the facility failed to fully develop, review with the resident and/or his responsible party and implement a person-centered baseline care plan within 48 hours of admission for Resident #2, Resident #8 and Resident #17.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide appropriate treatment and services to residents diagnosed with dementia for three (#17, #5 and #3) of five residents out of 17 sample residents. Specifically the facility failed to:-Develop a person-centered care plan to meet Resident #17's dementia care needs;-Ensure Resident #5 was provided activities to meet her preferences; and,-Develop and implement a person-centered care plan to meet Resident #3's dementia care needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#2) of six residents out of 17 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to effectively resolve and demonstrate the facility's response to individual grievances for Resident #2.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper personal hygiene and good nutrition for two (#3 and #7) of five residents reviewed for ADLs out of 17 sample residents. Specifically, the facility failed to:-Ensure Resident #3 consistently received assistance with meals and showers; and, -Ensure Resident #7 received assistance with showers.

Inspectors wroteBased on observations, record review and interviews, the facility failed to keep medical records in a secure and confidential manner. Specifically, the facility failed to ensure nursing staff logged off their workstation when leaving the work area to protect the confidentiality of resident information.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were provided an environment as free of accident hazards as possible for one (#32) of two residents reviewed for accidents and hazards out of 40 sample residents. Specifically, the facility failed to: -Ensure a thorough investigation was conducted after a skin tear was acquired during a staff-assisted transfer for Resident #32; and, -Identify the root cause of Resident #32's skin tear.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pain management regimen consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goal for one (#32) of two residents out of 40 sample residents. Specifically, the facility failed to, for Resident #32: -Ensure a pain assessment was completed that identified the type of pain, the effects of pain on the resident, the aggravating factors and the relieving factors; -Ensure person centered non-pharmacological interventions for pain management were offered and monitored for effectiveness; and, -Ensure the administration of pain medications was documented consistently.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#98) of six residents reviewed for unnecessary medications out of 40 sample residents was free from unnecessary medications. Specifically, the facility failed to: -Ensure Resident #98's hours of sleep were documented for psychotropic medication use; and, -Ensure person-centered interventions to address Resident #98's repetitive statements were identified and attempted prior to ordering an antipsychotic medication for the resident.

Inspectors wroteBased on record review and interviews, the facility failed to meet all of the requirements for the provision of hospice for one (#19) of one resident reviewed for hospice services out of 40 sample residents. Specifically, the facility failed to ensure a hospice care plan was initiated for Resident #19 to determine who was responsible for resident care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNA) consisted of annual training for dementia management and/or annual abuse training for three of three out of eight sampled staff. Specifically, the facility failed to ensure: -CNA #3, CNA #4 and CNA #5 completed the annual dementia and abuse training.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure menus were followed to meet the nutritional needs of residents. Specifically the facility failed to follow the menu, menu items were omitted without substitutions being made of the same nutritional value, and did not follow extensions for the pureed and mechanical soft diets.

Inspectors wroteBased on observations, record review and interviews, the facility failed to follow infection prevention and control procedures during resident care. Specifically, the facility failed to: -Perform hand hygiene before entering or after leaving resident's rooms and in between tasks; -Perform hand hygiene for residents before meals; and, -Disinfect equipment in between resident use

Inspectors wroteBased on observations and interviews, the facility failed to follow the infection control measures to prevent the potential cross contamination of SARS-CoV-2 COVID-19, during testing procedures on visitors and staff. Specifically, the front desk staff failed to wear proper personal protective equipment (PPE), a protective gown, gloves and N95 mask, consistently when collecting SARS-CoV-2 COVID-19 specimens from visitors and staff.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents have the right to receive visitors of their choosing at the time of their choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident. Specifically, the facility failed to allow visitation except in cases of Hospice care and compassion care visits for all residents. I. Facility policy Visitation policy was requested, the updated, untitled policy, revised 11/12/21, was provided by the nursing home administrator (NHA) on 1/4/22 at 10:00 a.m. The policy included: Visitation is now allowed for all residents at all times, in accordance with adherence to the core principles of COVID-19 infection prevention and control to mitigate the risk of infection spread. Indoor visitation: [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to administer oxygen in a manner consistent with professional standards of practice for three (#32, #49 and #55) out of five sample residents out of 40 total sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Resident #49, and #55 and #32.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure pain management program was in a manner consistent with professional standards of practice for two (Resident #55 and Resident #75) of three out 40 total sample residents. Specifically, the facility failed to: -Follow pain medication parameter order, and ensure all pain medications have a pain level parameter ordered for Resident #55 and #75; -Complete comprehensive pain evaluation every week as ordered for Resident #55 and #75; and, -Follow thecare plan for Resident #55 and #75 and attempt non pharmacological interventions prior to providing as needed pain medication.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure one (Resident #55) out of one reviewed for dementia care out of 40 total sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to implement person-centered and non- pharmacological interventions to address the Resident #55 dementia care needs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure as needed (PRN) orders for psychotropic drugs were evaluated by a physician within 14 days for use and duration for one (#11) of five residents reviewed for unnecessary medication use out of 40 sample residents. Specifically, the facility failed to: -Re-evaluate the use of a PRN psychotropic medication by a physician within 14 days; and, -Try non-pharmacological interventions and document the outcome prior to the administration of a PRN anti-anxiety medication. I. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included disorder of the brain, ataxia, and depression. -The resident did not have a diagnosis of anxiety. [...]