City Park Healthcare and Rehabilitation Center

Inspectors wroteBased on record review and interviews, the facility failed to provide response, action and rational to residents involved in group grievances. Specifically, the facility failed to address and document resolutions to resident concerns brought up in the resident council meetings in a timely manner.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of diseases and infection on two of five units. Specifically, the facility failed to;-Ensure housekeeping staff followed proper cleaning procedures for cleaning and disinfecting resident rooms and high-frequency touched areas (door handles, call lights, and bedside tables);-Ensure areas were cleaned from clean to dirty areas;-Ensure surface disinfectant dwell times (the amount of time a disinfectant needs to remain wet on a surface to effectively kill germs) were followed;-Ensure hand hygiene was performed appropriately during the cleaning of residents' rooms; and, -Failure to use appropriate PPE during wound care for enhanced barrier precautions.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#21) of one resident out of 46 sample residents were provided prompt efforts by the facility to resolve a grievance. Specifically, the facility failed to complete and provide prompt resolution to grievances for Resident #21.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#23) of three residents reviewed for accidents out of 46 sample residents received adequate supervision to decrease and/or prevent risk for accident hazards. Specifically, the facility failed to reassess Resident #23 for safe smoking practices.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for two (#2 and #1) of three residents reviewed for dialysis out of 46 sample residents. Specifically, the facility failed to:-Ensure Resident #2's blood pressure was taken post dialysis treatment according to the physician's order and resident's comprehensive care plan; and,-Ensure the facility followed up on Resident #1's dialysis facility's fluid restriction recommendation on the dialysis communication form.

Inspectors wroteBased on observations and interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation for five of eight resident bathrooms. Specifically, the facility failed to ensure the exhaust fans in five resident bathrooms were functioning.

Inspectors wroteBased on record review and interviews, the facility failed to provide services in accordance with accepted professional standards for one (#4) of four residents reviewed for ostomy care out of four sample residents. Specifically, the facility failed to ensure Resident #3 was provided appropriate ostomy care per physician's orders.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of four residents were free from abuse out of 18 sample residents. Specifically, the facility failed to ensure Resident #1 was free from abuse from Resident #2. Resident #1 was admitted on [DATE] with diagnoses of dementia and right-sided hemiplegia and hemiparesis following cerebral infarction. Resident #2 was admitted on [DATE] with diagnoses of diabetes mellitus type 2, dementia with behavioral disturbance, schizoaffective disorder, heart disease and chronic kidney disease. On 9/7/25 Resident #1 told Resident #2 to shut up. Resident #2 responded by pushing Resident #1. Resident #1 fell to the ground and sustained a left wrist fracture.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#1) of three residents was free from abuse out of six sample residents. Specifically, the facility failed to prevent and protect Resident #1 from verbal abuse by a staff member who yelled and cursed at Resident #1.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents and or their representatives were provided prompt efforts by the facility to resolve grievances for three (#1, #2 and #3) of three residents out of three sample residents. Specifically, the facility failed to address, resolve, document and follow up on grievances for: -Resident #1 regarding missing medications, call light wait times and schedule to ensure he arrived to dialysis timely; -Resident #2 regarding the staff getting him out of bed, call light wait times and providing showers; and, -Resident #3 regarding extended call light wait times.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one (#1) of three residents reviewed for dialysis out of three sample residents. Specifically, the facility failed to ensure Resident #1 was ready to leave the facility timely in order to get to dialysis to receive all ordered dialysis treatment.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents out of 3 sample residents did not experience a significant medication error. Specifically, the facility failed to ensure that Resident #1 received all doses of his prescribed kidney failure medication, Velphoro, which resulted in a significant medication error of omission.

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to: -Ensure proper hand hygiene and maintain a sanitary environment where food was being served; and, -Ensure the refrigerators on the units were cleaned properly.

Inspectors wroteBased on record review and interviews, the facility failed to prevent misappropriation of property for four (#19, #44, #48 and #49) of five residents reviewed for misappropriation out of 46 sample residents. Specifically, the facility failed to prevent staff members from exploiting money from Residents #19, #44, #48 and #49.

Inspectors wroteBased on interviews and record review, the facility failed to notify the state mental health agency promptly after a significant change in the mental condition of three (#33, #36 and #97) of seven residents reviewed for preadmission screening and resident review (PASRR) out of 46 sample residents. Specifically, the facility failed to: -Notify the state mental health agency of Resident #33, and Resident #97 necessity for inpatient psychiatric hospitalizations, and, -Notify the state mental health agency of worsening symptoms for Resident #36.

Inspectors wroteBased on observations and interviews, the facility failed to safely store and properly dispose of medications in a manner consistent with standards of practice for two of four medication storage rooms. Specifically, the facility failed to ensure: -Expired medications were discarded and removed from the medication storage room refrigerators in a timely manner; -All drugs and biologicals were kept safe and secure in locked compartments when not in direct line of sight of nurse; and, -All refrigerated drugs and biologicals were monitored daily for proper temperature controls in accordance with manufacturers specifications

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Ensure continuous positive airway pressure (CPAP) masks were stored off the floor, in a clean bag and replaced when contaminated; -Ensure staff performed hand hygiene during medication administration; and, -Ensure staff disposed of needles appropriately.

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure self-administration of medications was clinically appropriate for one (#39) resident out of 46 sample residents. Specifically the facility failed to: -Ensure Resident #39 was assessed for the appropriateness and safety of self-administration of oral medications; and, -Ensure there was a physician order for self-administration of oral medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a clean, comfortable, homelike environment. Specifically, the facility failed to ensure resident rooms were clean to minimize odors and in good repair.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#48) of two residents reviewed for abuse out of 46 sample residents were free from abuse. Specially, the facility failed to prevent a resident to resident altercation between Resident #48 and Resident #66.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a resident was free from physical restraints imposed for purposes of convenience, and that are not required to treat the resident's medical symptoms, the least restrictive alternatives was not used for one (#102) of one resident reviewed for restraint use out of 46 sample residents. Specifically, the facility failed to -Attempt to assess less restrictive alternatives to prevent Resident #102 from falling out of his wheelchair; -Evaluate the risks and benefits for using a lap belt or personal restraint on Resident #102; -Obtain a physician's order before implementing the use of a lap belt personal restraint on Resident #102 while in his wheelchair; -Re-evaluate the ongoing use of a lap belt personal restraint on Resident #102; [...]

Inspectors wroteBased on interviews, observations and record review, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation report into the assessment, care planning and transitions of care for one (#83) of four residents reviewed for PASRR out of 46 sample residents. Specifically, the facility failed to take steps to: -Ensure services were timely provided as recommended in Resident #83's PASARR level II; and, -Develop a PASARR level II care plan for Resident #83.

Inspectors wroteBased on observation, record review and interviews, the facility failed provide care and services for activities of daily living including speech, language and other communication systems for one (#12) resident of one reviewed out of 46 sample residents. Specifically, the facility failed to: -Ensure Resident #12 was able to communicate in her preferred language; and, -Ensure the communication book was available for Resident #12 use.

Inspectors wroteBased on record review, and staff interviews, the facility failed to clarify resuscitation choices and document them accurately in the medical record for one (#70) of three residents reviewed for advance directives out of 46 sample residents. Specifically, the facility failed to ensure the medical orders for scope of treatment forms (MOST) form matched the physician's orders for Resident #70's cardiopulmonary resuscitation (CPR) wishes.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental and psychosocial well-being were provided for two (#11 and #83) of four residents reviewed for meaningful activity programming activities out of 46 sample residents. Specifically, the facility failed to ensure: -Resident #11 received individualized meaningful activities to meet her social, emotional and recreational needs; and, -Resident #83 received a schedule of upcoming activities and was invited to activities and informed where the activity would be occurring.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide one (#99) of five residents reviewed for pressure injuries out of 46 sample residents with the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing. Specifically,the facility failed to: -Reposition the resident, who had pressure injuries; -Follow orders specifically to float heels while the resident was in bed; and, -Follow current orders for supplements to assist with wound healing and minimize further skin breakdown.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#99) resident of two out of 46 sample residents had pain management services consistent with professional standards of practice. Specifically, the facility failed to: -Ensure as needed (PRN) pain scale was implemented and followed for administration of morphine for Resident #99; and, -Pain medication was not administered according to the physician's orders for Resident #99.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services for s to attain and maintain the highest practicable mental and psychosocial wellbeing for two (#33 and #97) of three residents reviewed out of 46 sample residents. Specifically, the facility failed to ensure individualized, non-pharmacological approaches to care were being identified and promoted to meet the mental and psychosocial needs for Resident #33 and Resident #97.

Inspectors wroteBased on observation, record review and interviews, the facility failed to consistently provide appropriate treatment and services for dementia care for one (#99) of two residents with dementia out of 46 sample residents. Specifically, the facility failed to: -Provide a person-centered approach, individualized approach and treatment to Resident #99; and, -Have consistent, purposeful and meaningful activity for Resident #99.

Inspectors wroteBased on observations, document review, interviews, and review of the facility policy, the facility failed to ensure food items were stored, prepared, distributed, and served in accordance with professional standards for food safety in 1 of 1 kitchen. Specifically, the facility failed to ensure: 1. the kitchen staff dated, labeled, and covered food items in storage. 2. raw foods were not stored next to ready-to-eat foods. 3. dented cans were discarded. 4. kitchen staff wore a complete hair covering at all times when in the kitchen. 5. kitchen staff maintained the overall cleanliness of the kitchen. 6. kitchen staff maintained complete and accurate refrigerator and freezer temperature logs. This had the potential to affect all residents.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure residents were assessed for self-administration of medications for 2 (Residents #99 and #100) of 5 residents observed during medication administration.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure an allegation of verbal abuse was thoroughly investigated for 1 of 3 facility reported incidents for verbal abuse that were reviewed. This failed practice affected Resident #257.

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy, the facility failed to ensure care and services were provided in accordance with the comprehensive care plan for 1 (Resident #57) of 5 sampled residents reviewed for supplemental nutritional items.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure care plans were revised when needed for 1 (Resident #96) of 1 residents reviewed for oxygen administration. Cross reference F695, Respiratory Care.

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy, the facility failed to ensure care and services were provided in accordance with physician orders and accepted standards of practice for 1 (Resident #57) of 1 sampled resident reviewed for the use of straws for the oral intake of fluids.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure oxygen was administered at the flowrate prescribed by the physician for 1 (Resident #96) of 1 sampled resident reviewed for oxygen administration.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure a medication error rate of less than 5% for 2 (Resident #75 and Resident #100) of 5 residents observed during medication administration. Observations during medication administration revealed there were two medication errors out of 32 opportunities, which resulted in a 6.25% medication error rate.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident was not served food items that had been reported as a dislike and/or allergy for 1 (Resident #40) of 4 sampled residents reviewed for food concerns.

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to ensure hand hygiene was performed between dirty and clean tasks during wound care for 1 (Resident #60) of 1 sampled resident who was reviewed for wound care.