Complete Care at Park Place LLC

Inspectors wroteBased on observation, interviews, and facility document review, the facility failed to ensure personal protective equipment (PPE) was worn by laundry staff in one of one laundry rooms while sorting soiled resident clothing and bed linens. This had the potential to infect the staff and/or residents with pathogens which could potentially lead to the development of infectious diseases.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain a safe, clean, comfortable, and homelike environment on the memory care unit. Specifically, the floor in the dining/activity area was observed to be sticky. Additionally, a large table surface was visibly dirty. The sticky floor posed a potential risk for residents who ambulate, as it could contribute to loss of balance of falls. The unclean condition of the table had the potential to attract pests.

Inspectors wroteBased on record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that a comprehensive Minimum Data Set (MDS) assessment was completed accurately to reflect post-traumatic stress disorder (PTSD) for one of four residents (R87) reviewed for mood/behavior related to PTSD in the sample of 25 residents. This failure had the potential to affect the care planning and provision of needed services.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the baseline care plan included information necessary to meet the care needs for one of two sampled residents (Resident (R) 91) reviewed for dialysis. Specifically, the baseline care plan did not address peritoneal dialysis (PD). This failure had the potential to result in staff lacking the necessary guidance to provide effective care and meet the resident's needs.

Inspectors wroteBased on record review, interview, review of Resident Assessment Instrument (RAI) User's Manual, and policy review, the facility failed to develop person-centered, comprehensive care plans with measurable goals and interventions for two residents (Resident (R) 13 and R87) reviewed for care plans out of a sample of 25 residents. The failure placed R13 at risk for skin breakdown due to incomplete and/or inconsistent care to prevent pressure ulcers and placed R87 at risk for compromised emotional stability and impaired daily functioning related to a diagnosis of Post Traumatic Stress Disorder (PTSD).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents received services to maintain or improve their activities of daily living (ADLs) for one of one resident (Resident (R) 19) reviewed for ADLs out of a sample size of 25 residents. Specifically, R19 was not properly assessed by the facility's interdisciplinary team prior to the staff altering the method of meal consumption by placing pureed food and thickened liquids into a plastic cup for the resident to consume. This had the potential for the resident to experience a decline in functioning.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to administer oxygen in accordance with physician orders, document oxygen use, and change oxygen tubing for one of two residents (Resident (R) 87) reviewed for oxygen therapy out of a total of 25 sampled residents. This failure had the potential to place the resident at risk for adverse outcomes related to improper oxygen administration, including hyperoxia, a condition in which cells, tissues, and organs are exposed to an excessive level of oxygen.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure that, prior to the installation of bed rails, alternative measures were attempted, discussions regarding the risks versus benefits were documented, and signed informed consent was obtained for one of four residents (Resident (R) 108) reviewed for bed rails out of 25 sampled residents. The failure to complete these required steps before bed rail installation increased the potential risk for resident entrapment or for bed rails to be used as restraints.

Inspectors wroteBased on interviews, record review, and hospice agreement review, the facility failed to obtain documentation of recertification of hospice services for one of one resident (Resident (R) 14) reviewed for hospice services out of a total sample of 25 residents. This had the potential to result in a lack of coordination of care and services.

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow a physician's order for a resident who required a continuous positive airway pressure (C-PAP) machine at night. This deficient practice was identified for one (1) of two (2) residents reviewed for Respiratory Care (Resident #33), and was evidenced by the following: During the initial tour of the facility on 8/22/24 at 09:35 AM, the surveyor observed an oxygen concentrator near Resident #33's bed. At that time, the surveyor did not observe a C-PAP machine (delivers oxygen via a mask while asleep) in the resident's room. According to the admission Record, Resident #33 was admitted to the facility with diagnoses which included but not limited to: [...]

Inspectors wroteBased on observations, record reviews, interviews, and policy review, the facility failed to ensure that one of one resident (Resident (R) 23) reviewed for tracheostomy (trach) care out of a total sample of 20 residents was provided necessary suctioning of the airway, had the necessary supplies at the bedside in the event of a life-threatening emergency, and failed to train staff on appropriate emergency tracheostomy care in the event that a resident's airway was compromised, which placed residents with a tracheostomy at increased likelihood of serious harm or death and resulted in harm to R23 who was admitted to the hospital with diagnoses of pneumonia due to an infectious organism, AMS (altered mental status), SOB (shortness of breath), rigors (fever causing severe chills and shaking), respiratory distress, increasingly thick trach secretions, and sepsis (injury to tissues and organs [...]

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure the physician clarified orders for suctioning and emergency tracheostomy care for one of one resident (Resident (R) 23) with a tracheostomy (a surgical opening into the windpipe for breathing) out of a total sample of 20 residents. These failures resulted in harm to R23 who was admitted to the hospital with diagnoses of pneumonia due to an infectious organism, AMS (altered mental status), SOB (shortness of breath), rigors (fever causing severe chills and shaking), respiratory distress, increasingly thick trach secretions, and sepsis (injury to tissues and organs due to infection).

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure the clinical staff were trained to provide emergency treatment for one of one resident (Resident (R) 23) with a tracheostomy (surgical incision into the windpipe for breathing) out of a total sample of 20 residents. This failure increased R23's risk of not receiving appropriate tracheostomy care during an emergency situation.

Inspectors wroteBased on observation, interviews, record reviews, and review of facility policy, the facility failed to ensure one of 20 sampled residents (Resident (R) 23) had a physician's order and was assessed and care planned for the self-administration of medications. This failure increased the risk of incomplete or inaccurate administration of medication for R23.

Inspectors wroteBased on observations, record reviews, staff interviews, and policy review, the facility failed to ensure care plan interventions for emergency tracheostomy (trach) care were developed for one of one resident (Resident (R 23) reviewed for tracheostomy (a surgical opening into the windpipe for breathing) care out of a total sample of 20 residents. This failure increased R23's risk for compromised airway/respiratory distress and/or respiratory infections.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to provide a discharge assessment and discharge plan, for one of three residents (Resident (R) 39) reviewed for discharge out of a total sample of 20 residents. This failure increased the risk of delayed and/or incomplete discharge planning for residents wanting to be discharged from the facility.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure two of two residents (Resident (R) 54 and R69) reviewed for limited Range of Motion (ROM) out of a total sample of 20 residents was provided treatment to maintain and/or increase ROM. This failure increased the risk of a decline in ROM for residents that require treatment.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure an indwelling catheter was anchored to prevent excessive tension on the catheter tubing for one of two residents (Resident (R) 54) reviewed for catheter care out of a total sample of 20 residents. This failure increased R54's risk of injury to the urinary tract.