Park Center Healthcare and Rehabilitation

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #80 was provided privacy while being changed. This affected one (Resident #80) of three residents reviewed for privacy. The facility census was 93.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure a comprehensive assessment, and periodic reassessments of a seatbelt restraint were completed for Resident #88. This affected one (Resident #88) of one resident reviewed for restraints. The facility census was 93.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure safe smoking practices for Resident #83. This affected one (Resident #83) of five residents reviewed for smoking. In addition, the facility failed to ensure there was a fire blanket or fire extinguisher was observed in the designated smoking area. This had the potential to affect 30 (Residents #2, #4, #7, #10, #19, #23, #27, #28, #30, #31, #32, #36, #38, #42, #43, #46, #52, #65, #73, #75, #76, #78, #79, #83, #85, #86, #91, #92, #93, #94 and #96) identified by the facility as residents who smoked. The facility census was 93.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure lab work was obtained as ordered for Resident #5. The affected one (Resident #5) of three residents reviewed for laboratory services. The facility census was 93.

Inspectors wroteBased on medical record review, observation, staff interview and facility policy review, the facility failed to ensure Resident #80's medical record was accurate to reflect the refusal of the right-hand splint. This affected one (Resident #80) of three residents reviewed for split use. The facility census was 93.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to utilize enhanced barrier precautions (EBP) during wound care when required. This affected one (Resident #6) of two residents reviewed for EBP. There were eight (Residents #6, #24, #68, #70, #76, #82, #88 and #92) who required EBP. The facility census was 93.

Inspectors wroteBased on observation, record review and interview the facility did not ensure palatable food was served at residents meals. This affected four residents (Resident #11, #32, #69 and #90) of six residents reviewed for food/nutrition. The facility census was 92.

Inspectors wroteBased on record review, interview and review of the facility policy the facility failed to ensure Resident #45's responsible party was included in the development and revision of the care plan for Resident #45. This affected one resident (Resident #45) out of three residents reviewed for participation in care planing. The facility census was 92.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #45's change in condition was reported to Resident #45's primary care physician and responsible party in a timely manner. This affected one resident (Resident #45) out of three residents reviewed for change of condition. The facility census was 92.

Inspectors wroteBased on observation, interview, record review and review of bowel and bladder assessments the facility failed to ensure Resident #45 was provided toileting assistance to maintain a level of ability with toileting activity of daily living. This affected one resident (Resident #45) out of three residents reviewed for Activity of Daily Living's. The facility census was 92.

Inspectors wroteBased on observation, interview and review of facility policy the facility did not ensure a safe, functional, sanitary, and comfortable environment for all residents. This had the potential to affect all 92 residents living in the facility.

Inspectors wroteBased on observation, interview and policy review the facility failed to ensure food was stored and served in a manner to prevent contamination and food born illness. This had the potential to affect all 92 residents residing in the facility. There were no residents identified as having a nothing by mouth diet. The facility census was 92.

Inspectors wroteBased on observation, interview and policy review, the facility failed to provide a clean and homelike environment. This affected five residents (#42, #52, #62, #65) and had the potential to affect 16 residents living on Hall 2A (#79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93 and #94)) and 25 residents living on Hall 3B (#52, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #75, #76, #77 and #78). The facility census was 92.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure all residents were provided therapeutic activities as scheduled and in the evenings to meet their needs and preferences. This affected all 92 residents residing in the facility. The facility census was 92.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to store Tuberculin Purified Protein (serum used for intradermal injection to test for tuberculosis) and Lispro Insulin in a manner to ensure efficacy of the medication. This affected one resident (#18) whom the Lispro Insulin was prescribed for and had the potential to affect all residents residing in the facility. The facility census was 92.

Inspectors wroteBased on interview and record review, the facility failed to ensure they had a qualified food service director. This had the potential to affect 92 residents who received food from the kitchen. The facility identified all residents in the facility received food from the kitchen. The facility census was 92.

Inspectors wroteBased on observation, interviews, and review of facility policy, the facility failed to ensure the facility menu was well balanced in regards to calcium sources for all residents. This had the potential to affect all 92 residents receiving meals from the kitchen. The facility identified zero residents as receiving nothing by mouth (NPO). The facility census was 92.

Inspectors wroteBased on observation, interviews, record reviews and review of facility policy, the facility failed to ensure resident food preferences were honored and appropriate substitutions were made per resident preferences. This had the potential to affect all 92 residents who received meals from the kitchen. The facility identified zero residents as receiving nothing by mouth (NPO). The facility census was 92.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure proper sanitation was followed in the kitchen and during meal tray delivery. This had the potential to affect all 92 residents in the facility. The facility identified zero residents as receiving nothing by mouth (NPO). The facility census was 92.

Inspectors wroteBased on observation, interview, and review of the facility policy, the facility did not maintain garbage and refuse properly in a closed dumpster free of surrounding litter. This had the potential to affect all residents residing in the facility. The census was 92.

Inspectors wroteBased on observation, record review, job description review, and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect all 92 residents who resided in the facility. The facility census was 92.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to develop and implement a system to address, analyze, monitor and resolve quality assurance and performance improvement related to the pervasive and ongoing food quality concerns in the facility. This had the potential to affect all 92 residents residing in the facility, as the facility identified zero residents who did not eat by mouth (NPO). The facility census was 92. Findings Include: [...]

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure appropriate infection control procedures were followed regarding transmission-based precautions (TBP) and enhanced barrier precautions (EBP), failed to separate clean and dirty linens, failed to ensure an effective Legionella water management program, failed to ensure appropriate nebulizer and oxygen tubing storage, and failed to clean multiuse glucometers according to facility policy. This affected 17 residents (#2, #5, #9, #16, #27, #31, #32, #43, #45, #46, #49, #50, #58, #79, #84, #195 and #197) of 32 residents reviewed for infection control and had the potential to affect all 92 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility did not ensure all residents were treated with a dignified dining experience due to serving meal trays without providing knives to cut food and apply condiments to their foods. This affected all 64 residents receiving meals from the kitchen excluding two residents the facility identified as receiving pureed diets (Resident #8 and #85) and 24 residents (#6, #7, #10, #15, #30, #33, #34, #37, #39, #40, #41, #45, #53, #55, #59, #64, #68, #70, #72, #75, #78, #80, #86, and #89) who resided on the secured behavior unit where knives were not provided at meal times for safety. The facility also did not ensure Resident #45 had a privacy curtain. This affected one resident (#45) of 92 residents reviewed for privacy curtains. The facility census was 92.

Inspectors wroteBased on record review and interviews, the facility failed to resolve ongoing food related concerns expressed at resident council. This affected five residents (Resident # #1, #4, #22, #29 and #54) of 92 residents receiving meals from the kitchen. The facility census was 92. Findings Include: [...]

Inspectors wroteBased on observation, interview and policy review the facility failed to repair or replace broken window blinds for 14 residents (#11, #17, #24, #36, #42, #43, #46, #49, #54, #56, #60, #62, #71 and #91) and failed to provide an adequately clean room for Resident #16. This affected a total of 15 residents out of 92 residents reviewed for a safe/clean/comfortable environment. The facility census was 92.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen and nebulizers were stored and administered according to physician's orders. This affected five residents (Residents #16, #45, #52, #71, and #246) of five reviewed for respiratory care. The facility identified 10 residents as using oxygen and/or nebulizer treatments. The facility census was 92.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were within reach for Resident #8 and #67. This affected two residents (#8 and #67) of 32 residents reviewed for call light accessibility. The facility census was 92.

Inspectors wroteBased on review of resident funds accounts, medical record review and staff interview, the facility failed to ensure resident funds were maintained under the Medicaid limit. This affected one resident (#8) of five residents reviewed for personal funds. The facility census was 92.

Inspectors wroteBased on medical record review, interview, and facility policy review the facility failed to ensure a resident's wishes regarding end-of-life measures were clearly identified in the medical record. This affected one resident (Residents #196) of three residents reviewed for Advanced Directives. The facility census was 92.

Inspectors wroteBased on record review, interview, review of a Self-Reported Incident (SRI) and facility policy review the facility failed to thoroughly investigate potential resident to resident abuse as required. This affected two residents (#33 and #346) of three residents reviewed for abuse. The facility census was 92.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure resident assessments accurately reflected the dental status for Resident #28 and #196. This affected two residents (Residents #28 and #196) of 32 residents reviewed for accurate resident assessments. The facility census was 92.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were updated to accurately reflect resident's needs. This affected three residents (residents #31, #50, and #71) of 32 residents reviewed for care plans. The facility census was 92.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure showers and nail care were provided consistently and according to resident preference. This affected two residents (resident #28 and #50) of five reviewed for assistance with daily living (ADL)'s. The facility census was 92.

Inspectors wroteBased on record review, observation, interview, and facility policy review the facility failed to ensure Resident #24 who was at risk for elopement was adequately supervised while outside smoking, did not ensure for Resident #4 that the appropriate safe smoking equipment and supervision were provided during smoking break, and did not ensure fall interventions were in place for Resident #72. This affected three residents (#4, #24 and #72) of five residents reviewed for accidents/hazards. The facility census was 92.

Inspectors wroteBased on record review and staff interview the facility failed to ensure accurate weights were obtained as ordered. This affected two residents (Residents #50 and #196) of three residents reviewed for nutrition. The facility census was 92. Findings Include: 1. Review of the medical record for Resident #50 revealed an admission date of 03/07/24. Diagnoses included pneumonia, acute kidney failure, depression, anxiety disorder, type two diabetes mellitus without complications, dysphagia (difficulty swallowing), essential hypertension (high blood pressure), and personal history of transient ischemic attack (TIA) and cerebral infarction (stroke) without resident deficits. Review of the most recent Minimum Data Set assessment dated [DATE] revealed Resident #50 was severely impaired cognitively, required supervision or touch assistance for eating, and was on a mechanically altered diet. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure dialysis orders were accurate and assessments were completed before and after dialysis. This affected one resident (Resident #196) of two reviewed for dialysis. The facility census was 92.

Inspectors wrote3. Review of medical record for Resident #45 revealed an admission date of 04/29/21. Medical diagnoses included occlusion and stenosis of bilateral carotid arteries, ischemic cardiomyopathy, acute ischemic heart disease, chest pain, unspecified convulsions, type two diabetes mellitus, chronic obstructive pulmonary disease, unspecified dementia, post-traumatic stress disorder (PTSD), major depressive disorder, suicidal ideations, personality disorder, anxiety disorder, other psychoactive substance abuse. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #45 was moderately cognitively impaired. Resident #45 showed no mood or behavior concerns and did not exhibit the behavior of rejection of care. [...]

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to document appropriate justifications for declining a gradual dose reduction (GDR) recommendation for Resident #31. This affected one resident (#31) out of seven residents reviewed for unnecessary medications and had the potential to affect all residents in the facility. The facility census was 92.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of pain medication for Resident #52. This affected one resident (#52) of seven residents reviewed for unnecessary medication. The facility census was 92.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure appropriate diagnoses for medications and failed to ensure behaviors were tracked for medication efficacy. This affected three residents (#31, #35 and #71) of seven residents reviewed for unnecessary medications. The facility census was 92.

Inspectors wroteBased on medical record review, interview, observation and policy review the facility failed to ensure daily weights were documented per physician orders related to congestive heart failure monitoring for Resident #45. The facility also failed to ensure Resident #196's diet order accurately reflected the resident's dietary needs. This affected two resident's (#45 and #196) of 32 residents reviewed for documentation. In addition, the facility failed to have documented evidence of weekly body audits on Resident #79 as ordered to monitor the status of wounds. This affected one resident (#79) of three residents reviewed for pressure ulcers and had the potential to affect nine additional residents (#9, #27, #42, #43, #46, #49, #58, #74, and #195) identified by the facility as having wounds. The facility census was 92.

Inspectors wroteBased on observation, interviews, and review of the facility policy, the facility failed to ensure it had a functional call light system for Residents #27, #81, and #82. This affected three residents (#27, #81 and #82) out of 32 residents reviewed for call lights. The facility census was 92. Findings Include: 1. Record review for Resident #82 revealed an admission date of 06/06/23. Diagnoses included encounter for other orthopedic aftercare, presence of left artificial hip joint, bilateral primary osteoarthritis of hip, pain in left and right hip, major depressive disorder, generalized anxiety disorder, type two diabetes mellitus without complications, other abnormalities of gait and mobility, and muscle weakness (generalized). [...]

Inspectors wroteBased on record review, observation and interview, the facility failed to document in the medical record an incident involving Resident #14 getting stuck in a stairwell. This affected one resident (#14) of three residents reviewed for accurate documentation. The facility census was 91.

Inspectors wroteBased on medical record review, review of a self-reported incident (SRI), review of the local police report, review of the facility investigation, policy review, and resident and staff interviews, the facility failed to ensure residents were free from physical abuse by a staff member. This resulted in Immediate Jeopardy and serious psychosocial harm for Resident #72, when Licensed Practical Nurse (LPN) #315 pushed Resident #72's head into a wall and physically restrained Resident #72 with her hands around Resident #72's throat in response to aggressive behaviors exhibited by Resident #72 with resultant gasping for air, trying to say she could not breath, fear for her safety in the facility and subsequent sleep disturbance requiring the prescription of a hypnotic sleep medication and psychological counseling. This affected one resident (#72) of eight residents reviewed for abuse. [...]

Inspectors wroteBased on record review and interviews the facility failed to have a registered nurse (RN) for eight consecutive hours on 06/18/23. This had the potential to affect all 91 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident #8's call light did not have exposed wires, failed to ensure Resident #40's call light and bed controller were working appropriately, failed to ensure Resident's #24, #39, and #75 had a call light connected to the call light system in their rooms. This affected five residents (#8, #24, #39, #40 and #75) out of six residents reviewed for call lights. The facility census was 91.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy the facility failed to ensure the temperature on the third-floor nursing units were within the required temperature range of 71 to 81 degrees Fahrenheit. This affected one resident (#19) and had the potential to affect all 54 residents (#3, #4, #5, #7, #9, #10, #11, #13, #14, #15, #16, #18, #19, #20, #21, #23, #24, #25, #33, #36, #37, #39, #40, #41, #42, #43, #44, #45, #46, #47, #49, #50, #54, #56 #57, #58, #59, #60, #63, #66, #67, #68, #70, #71, #72, #75, #79, #80, #82, #83, #85, #88, #89, #195) residing on the third-floor of the facility. The facility census was 91.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to provide a written invitation or conduct an interdisciplinary team care plan meeting for Residents #22, #76, #48, #3, #11, #21, #33, #40, #45, #49, #51, #16, #44, #7, #24, #58, and #75. This affected 17 residents (#22, #76, #48, #3, #11, #21, #33, #40, #45, #49, #51, #16, #44, #7, #24, #58 and #75) out of 91 residents screened for plan of care meetings. The facility census was 91.

Inspectors wroteBased on record review, interviews and observations, the facility did not ensure food was served in a manner to maintain quality and palatability of all food served to the residents. This had the potential to affect all residents receiving meals from the kitchen. The facility census was 91.

Inspectors wroteBased on medical record review, interview, and facility policy review the facility failed to ensure resident wishes regarding end-of-life measures were clearly identified in the medical record. This affected two residents (#81 and #84) of three residents reviewed for Advanced Directives. The facility census was 91.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents discharged from skilled services were provided appropriate notification of services ending. This affected one resident (#251) of three residents reviewed for beneficiary notification. The facility census was 91.

Inspectors wroteBased on observation, interview, record review, and review of facility policy the facility failed to ensure Resident #88 did not have very long, dirty, yellow toenails. This affected one resident (#88) out of three residents reviewed for long toenails. In addition, the facility failed to ensure shower/bed baths were given to Resident #58 according to the physician's orders and plan of care. This affected one resident (#58) of six residents reviewed for activities of daily living (ADL). The facility census was 91.

Inspectors wroteBased on observation, interview, record review, and review of facility policy the facility failed to ensure Resident #82's urine culture was collected and sent to the lab per physician's orders. This affected one resident (#82) out of three residents reviewed for urine cultures. The facility census was 91.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to prevent Resident #35's fall in the facility and failed to ensure fall prevention interventions were in place for Resident #8. This affected two residents (#35 and #8) out of five residents reviewed for falls. The facility census was 91.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #36 received nutritional supplements and double portions of food per physician orders, failed to ensure weights were obtained per physician orders, failed to ensure Resident #36's meal percentages of food eaten were documented and failed to ensure Resident #36's significant weight loss was monitored from 03/16/23 through 06/26/23. The facility failed to ensure Resident #82 was provided fluids per physician orders, failed to ensure Resident #82's fluid intake was recorded and failed to ensure Resident #82's daily fluid requirements were documented by the facility Dietician in an initial nutritional assessment. The facility also failed to obtain monthly weights as ordered for resident #32. [...]

Inspectors wroteBased on record review and interview the facility failed to obtain Resident #6's laboratory results during dialysis treatments as ordered by the physician. This affected one resident (#6) out of one resident reviewed for hemodialysis care. The facility census was 91.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were reviewed monthly. This affected one resident (#8) of five resident reviewed for unnecessary medications and had the potential to affect all residents in the facility. The facility census was 91.

Inspectors wroteBased on record review, interview, and review of the facility policy the facility failed to ensure non-pharmacological interventions were utilized, behavioral symptoms were monitored, and anti-anxiety medications were not used for longer than 14 days without a rationale. This affected one resident (#8) of five residents reviewed for unnecessary medications. The facility census was 91.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to ensure staff washed their hands to prevent possible cross contamination of infections during Resident #23's incontinence care and wound care. This affected one resident (#23) out of three residents reviewed for wounds and incontinence care. The facility census was 91.