Park Bend Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 8 residents (Resident #1) reviewed for resident rights. The facility failed to ensure the physician was notified from [DATE] through [DATE] when Resident #1 continued to have bloody urine draining from her indwelling urinary catheter. The physician was not notified until [DATE] that the resident was experiencing a change in condition, and the physician ordered for the resident to be sent to the hospital. At the hospital, the resident was diagnosed with severe sepsis with septic shock with a likely source of urinary tract infection. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 8 residents reviewed for catheter care. The facility failed to assess, intervene, and change Resident #1's indwelling urinary catheter when Resident #1's catheter was draining blood from [DATE] through [DATE]. On [DATE], Resident #1 was sent to the hospital for a change of condition and was diagnosed with severe sepsis with septic shock with a likely source of urinary tract infection. On [DATE] at 6:45 p.m. an IJ was identified. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two (Resident #57 and Resident #68) of five residents, reviewed for incontinence. 1. The facility failed to ensure Resident #57 and Resident #68 did not have their Foley Catheter bags lying on the ground. This failure placed residents at risk for healthcare associated cross contamination and urinary tract infections.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #24) of five residents, reviewed for infection control. 1. The facility failed to ensure CNA A performed hand hygiene after performing catheter care and a brief change for Resident #24. This failure placed residents at risk for healthcare associated cross contamination and infections. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 3(Resident#1, Resident#2 and Resident#3) of 10 residents reviewed. The facility failed to ensure Resident#1, Resident#2 and Resident#3 did not have drugs and biologicals at their bedside. This failure could place residents at risk of consuming or using wrong medications and biologicals that could lead to harm.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents were free from neglect for 1 of 4 residents (Resident #1) reviewed for neglect. 1. The facility failed to ensure Resident #1 was protected from neglectful treatment by failing to respond to family members performing medical procedures on her. 2. The facility delayed sending Resident #1 to the hospital after discovering family had started an IV on the resident. An IJ was identified on 05/22/25. The IJ template was provided to the facility on [DATE] at 5:10 PM. While the IJ was removed on 05/23/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 5 residents (Resident #1) reviewed for accident hazards. 1. The facility failed to implement interventions for Resident #1 to ensure she did not consume hand sanitizer after empty bottles of hand sanitizer were found in her room. 2. The facility failed to ensure Resident #1 did not keep aspirin at her bedside. The noncompliance was identified at an Immediate Jeopardy (IJ) PNC (past nocompliance). The noncompliance began on 10/12/2024 and ended on 12/17/2024. The facility had corrected the noncompliance before the survey began. The Administrator was provided the IJ template on 02/27/25 at 5:32 PM. These failures could place residents at risk of harm, injury, or death.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable and homelike environment. The facility failed to ensure the front door was monitored from 5:00pm-7:00pm once the receptionist left for the day. Leaving the door unlocked and unattended allowed anyone to enter without knowledge. This failure could place residents at risk for living in an unsafe, unhomelike environment which could cause a decline in resident psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #138, Resident #19) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #138 had his fingernails cleaned and trimmed. 2- Resident #19 had her fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 3 Residents (Resident #36) reviewed for respiratory care. The facility failed to ensure Resident #36's nasal cannula tubing was labeled or dated. This failure could place residents at risk of respiratory infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (600 hall nurses' medication cart) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure the 600 Hall medication cart had 1 insulin pen for Resident #74 with no opened date. This failure could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Residents #52) of 9 residents observed for infection control. CNA A and CNA B failed to perform hand hygiene during incontinence care for Resident #52. This failure could place residents at risk for the development and/or worsening of urinary tract infections, cross contamination, and skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to allow the MPOA the right to participate in the development and implementation of the resident's person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care, (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care for one (Resident #1) of eight residents reviewed for resident rights. [...]

Inspectors wroteBased on interview and record review, the facility failed to Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision for one (Resident #1) of eight residents reviewed for grievances. The facility did not have any grievance resolution or grievance documentation related to Resident #1's MPOA expressed concerns related to her well-being, weight loss and lack of assistance with eating in emails to the facility management team. This failure could place residents at risk with unresolved grievances and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, and offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for one (Resident #1) of four residents reviewed for weight loss. 1. The facility failed to provide Resident #1 with care planned nutritional interventions and failed to ensure they were providing the physician ordered appetite stimulant medication Mirtazapine/Remeron in the correct hospice ordered dose from 07/24/24 through 08/08/24. 2. The facility failed to ensure the dietary orders for Resident #1 were followed. Resident #1's diet orders were subjective and not clear as to when staff could provide her a mechanical soft diet versus a pureed diet. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurate for 4 (Residents # 1, #2, #3, and #4) of 10 resident records reviewed. The facility failed to ensure the MAR for Residents #1, #2, #3, and #4 from 06/01/24 to 06/18/24 accurately reflected the administration of pain medications. This failure could cause residents to receive additional dosages and provide an inaccurate picture of the resident's helath to the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of ten residents reviewed for medication administration. MA A failed to administer medications accurately. Medications were observed in a medication cup, at Resident #1's bedside and MA A signed the MAR as administered. These failures could place residents at risk of consuming unsafe medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in accordance with State and Federal laws, in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one (Resident #1) of ten residents reviewed for medication administration. MA A failed to securely store Resident #1's medication; Resident #1's morning medications were observed in a medication cup on the bedside table. These failures could place residents at risk of consuming unsafe medications.

Inspectors wroteBased on interview and record review, the facility failed to provide and document an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 (Resident #1) of 6 residents reviewed for discharges. The facility failed to complete the process for home health services for Resident #1 to receive continued care for her IV antibiotics, needed for cellulitis to her left foot, prior to her discharge on [DATE]. Resident #1 had not received her antibiotics from 11/18/23 through 11/21/23 as a result of the facility's failure. An IJ was identified on 11/21/23. The IJ template was provided to the facility on [DATE] at 5:16 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice, and the residents' choices, for one (Resident #1) of six residents reviewed, in that: The facility failed to ensure the order from the hospital was transcribed onto the electronic health record after re-admission, failed to assess the resident as needed, check her glucose levels, and consult a physician. The resident did not receive insulin from the facility between 11/08/23-11/14/23, resulting in the resident being admitted to the hospital from a doctor's appointment, due to a high glucose level. An IJ was identified on 11/16/23. The IJ template was provided to the facility on [DATE] at 11:44 AM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident was free of any significant medication errors for one (Resident #1) of six residents reviewed in that: 1. Admitting Nurse/Agency Nurse C failed to add Resident #1's medication order for Basaglar Kwikpen U-100 Insulin to the electronic record. The facility did not administer insulin to Resident #1 from 11/08/23-11/14/23, resulting in the resident being admitted to the hospital from her doctor's visit due to a high glucose level. An IJ was identified on 11/16/23. The IJ template was provided to the facility on [DATE] at 11:44 AM. While the IJ was removed on 11/16/23, the facility remained out of compliance at a scop of isolated and a severity level of actual harm that is not Immediate Jeopardy, because all staff had not been trained on transcribing, neglect, and following-up on orders after admission. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 10 of 15 residents (Residents #1, #2, #4 , #6 , #7, #8, #9, #10, #11 and #12) in the facility reviewed for infection control practices and transmission-based precautions. The facility failed to ensure staff utilized PPE appropriately to prevent cross contamination between residents positive with COVID-19 and residents who were not positive for the virus. This failure could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items were kept away from potential airborne contaminants (dust and fuzz) on the ice machine. 2. The facility failed to properly label food items with the contents and date the items were placed in the refrigerator in accordance with professional standards. 3. The facility failed to ensure a trash bin in the dry food storage area of the kitchen was covered. These failures could place residents, who receive food from the kitchen, at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to make information on how to file a grievance or complaint available to the residents, including notifying residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed for 1 of (Resident #87) of 4 residents reviewed for grievances. 1. The facility failed to ensure Resident #87 knew how to file a grievance. 2. The facility failed to file a grievance for Resident #87 who complained that she had not received physical therapy. The facility's failure could place the residents at risk for concerns not being reported and addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #68) of 4 residents reviewed for intravenous fluids. The facility failed to ensure Resident #68 received PICC (PICC line is a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) line dressing changes as ordered. This failure could affect residents by placing them at risk for infection.