Park Health Center

Inspectors wroteBased on medical record review, policy review, facility self-investigation report review, review of police reports, resident observation, and interviews with residents and staff, the facility failed to complete a thorough investigation for an allegation of staff to resident sexual abuse. In addition, the facility failed to protect residents after an allegation of staff to resident sexual abuse when they permitted a specified perpetrator to continue to work and provide care to residents. This affected one resident (#171) of three residents reviewed for abuse, and eight residents (#102, #111, #121, #122, #124, #134, #142, and #143) who were provided care by a specified perpetrator who was the perpetrator identified in a staff to resident sexual abuse allegation and allowed to work. The facility census was 84.

Inspectors wroteBased on medical record review, facility policy review, facility investigation file review, police report review, resident observation, and resident and staff interview, the facility failed to report an allegation of staff to resident sexual abuse. This affected one resident (#171) of three residents reviewed for abuse. The facility census was 84.

Inspectors wroteBased on medical record review, review of the social services job description, and resident and staff interviews, the facility failed to provide medically related social services for a resident who had a change in her psychosocial status. This affected one resident (#171) of three residents reviewed for abuse.

Inspectors wroteBased on review of medical records, review of facility investigations, review of police reports, facility policy reviews, observations, and interviews with residents and staff the facility failed to provide effective administration when the facility's Administrator knowingly failed to report an allegation of staff to resident sexual abuse of Resident #171 and the Administrator knowingly provided false information to investigating police officers. This affected one resident (#171) of three residents reviewed for abuse. The facility census was 84.

Inspectors wroteBased on medical record review and staff interview the facility failed to maintain an accurate and complete medical record. This affected one resident (#171) of three residents reviewed for abuse. The facility census was 84.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, hospital documentation review, review of a facility investigation, review of video footage, policy review and interviews, the facility failed to timely and comprehensively assess, notify a physician, and provide timely and necessary care and services to Resident #22 after she complained of hip pain as a result of a dislocated right hip. This resulted in Immediate Jeopardy and Actual Harm beginning on 07/21/25 at 1:10 A.M. when Resident #22 voiced complaints of pain and staff continued to provide personal care, assisting the resident into her bathroom and transferred the resident to bed without first assessing the resident. [...]

Inspectors wroteBased on record review, policy review, review of video footage, and interview the facility failed to ensure a resident was treated with respect and dignity. This affected one resident (#22) of four residents reviewed for change in condition. The facility census was 86.

Inspectors wroteBased on record review, policy review, review of video footage, and interview, the facility failed to ensure a resident was provided the opportunity for urination in the bathroom versus being told to urinate in her incontinence brief. This affected one resident (#22) of four residents reviewed for change in condition. The facility census was 86.

Inspectors wroteBased on observation, policy and interview, the facility failed to ensure food was stored, and prepared under sanitary conditions. This affected all the resident's in the facility except Residents #8, #63, #133, #183, #185 and #189 who do not receive nutrition from the kitchen. The facility census was 83.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to ensure advanced directives were accurate. This affected one resident (#2) of 24 residents reviewed for advanced directives. The census was 85.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure plans of care were updated to reflect the residents' preferences and medical needs. This affected two Residents (#26 and #133) of 22 residents reviewed.

Inspectors wrote2. Review of Resident #70 revealed a 07/29/25 admission with diagnoses including Parkinson's disease, psychotic disorder with delusions, vitamin D deficiency, type 2 diabetes, and anxiety disorder. The admission shower preference sheet dated 07/29/24 indicated a preference for three to four showers a week. Review of the 01/27/25 Quarterly MDS revealed the resident was severely impaired for daily decision making, had hallucinations, delusions, rejection of care, physical and verbal behaviors, He had upper and lower functional impairment on both sides and dependent for bathing. Interview 03/24/25 at 11:47 A.M. with Resident #70's wife revealed the facility was not brushing his teeth, showering and completing dressing changes. He was supposed to be getting showers three times a week and he sometimes doesn't get two a week. [...]

Inspectors wroteBased on medical record review and interview the facility failed to ensure an anticoagulant (Eliquis) medication was administered per orders after the resident received a new diagnoses of pulmonary embolism (blockage of the main artery to the lung or one of its branches). This affected one (Resident #76) of six reviewed for unnecessary medication review.

Inspectors wroteBased on medical record review, review of operational manual, review of policy, review of statement, observation and interview the facility failed to ensure low air loss mattress was functioning properly. This affected one (Resident #240) of four residents reviewed for pressure ulcers.

Inspectors wroteBased on record review, and interview, the facility failed to ensure care was appropriate for a resident receiving dialysis services. This affected one (Resident #26) of one resident reviewed for dialysis.

Inspectors wroteBased on medical record review, observation, interview, and policy review the pharmacy failed to ensure medication were available timely for administration. This affected one (Resident #64) of three observed for medication administration, one (Resident #236) of two reviewed for urinary tract infections, and one (Resident #238) of one reviewed for respiratory infection.

Inspectors wroteBased on medical record review and interview the facility failed to ensure medication were administered per parameters. This affected one (Resident #76) of six reviewed for unnecessary medication review.

Inspectors wroteBased on medical record review, review of the Center for Disease Control (CDC), review of infection control log, interview, and policy review the facility failed to ensure resident's meet criteria for antibiotics treatment. This affected one (Resident #238) of one reviewed for respiratory infection.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, review of equipment manufacturer guidelines, policy review and interview, the facility failed to ensure Resident #1 was provided adequate and proper assistance, following manufacturer's guidelines to reposition in a geriatric (geri) chair to prevent an accident with injury. This affected one resident (#1) of three residents reviewed for accidents. The facility identified seven additional residents (Resident #11, #13, #15, #17, #18, #20, and #21) who utilized reclining assistive devices for mobility. The facility census was 71.

Inspectors wroteBased on observation, record review and interview the facility failed to store food properly, check temperatures on cold items prior to serving them, and ensure the oven was clean. This had the potential to affect 72 of 72 residents who received meals from the kitchen. The facility identified four residents, Resident #5, #29, #63, and #68 who received nothing by mouth and did not receive food from the kitchen. The facility census was 76.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was prepared to the ordered consistency. This had the potential to affect five residents (#20, #26, #37,#42, and #130) of five residents who were ordered pureed meals. The facility census was 76.

Inspectors wroteBased on observation, interview, resident record review, facility policy review and review Center for Disease Control (CDC) Guidelines, the facility failed to ensure proper personal protective equipment (PPE) was worn when care was provided to Resident #130 who was diagnosed with COVID-19. This had the potential to affect 39 (Resident #2, #3, #4, #5, #8, #9, #10, #11, #14, #15, #20, #21, #23, #24, #25, #26, #28, #30, #32, #33, #36, #37, #42, #45, #51, #53, #55, #56, #62, #63, #66, #67, #129, #130, #131, #132, #230, #229, and #231) of 39 residents residing on south wing without active COVID-19. The facility census was 76.

Inspectors wroteBased on record review, review of a list of psychotropic medications provided by the facility and interview, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARRs) were up to date and accurate. This affected two residents (#30 and #37) of two residents reviewed for PASARR. The facility census was 76.

Inspectors wroteBased on observation, record review, facility policy review and interview the facility failed to ensure residents' masks and tubing for their noninvasive ventilation were cleaned every morning as ordered and failed to ensure documentation regarding cleaning was accurate. This affected two residents (#9 and #66) of five residents reviewed for respiratory care. The facility census was 76.

Inspectors wroteBased on record review and interview, the facility failed to ensure medication orders were followed. This affected one resident (#20) of six residents reviewed for unnecessary medications. The facility census was 76.

Inspectors wroteBased on record review and interview, the facility failed to ensure hospice visitation notes, assessments and communication were maintained in Resident #16's medical record. This affected one resident (#16) of one resident reviewed for hospice services. The facility census was 76.

Inspectors wroteBased on observation, review of an end of shift checklist, facility policy and procedure review and interview the facility failed to ensure food was stored and prepared under sanitary conditions to prevent contamination spoilage and/or food borne illness. This had the potential to affect 74 of 74 residents who received meal trays from the kitchen. The facility identified three residents (#58, #74 and #475) who received nothing by mouth.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure all resident rooms were in good repair and properly cleaned. This affected four residents (#60, #35, #19 and #74) of 77 residents residing in the facility.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure insulin and tuberculin solution were labeled appropriately after opening. This affected eight residents (#4, #479, #1, #22, #52, #175, #65 and #39 and had the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure resident room repairs and issues were addressed timely after identification from staff. This affected 36 rooms of 52 rooms in the facility. The facility census was 77.

Inspectors wroteBased on resident funds review and interview the facility failed to ensure Resident #3's funds were safeguarded, properly managed and not returned to the Treasurer of Ohio following stimulus money received by the resident. This affected one resident (#3) of 43 residents identified to have personal funds managed by the facility.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure residents and/or resident representatives received bed hold notification prior to transfer to the hospital. This affected two residents (#74 and #76) of two residents reviewed for hospitalization.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #65 and Resident #69, who required staff assistance for activities of daily living received timely and adequate assistance with oral care and/or showers. This affected two residents (#65 and #69) of two residents reviewed for activities of daily living.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure urinary drainage bags were maintained without potential for contamination to decrease the risk of urinary tract infections and/or failed to ensure resident catheter orders were comprehensive and implemented as written. This affected two residents (#7 and #60) of two residents reviewed for urinary/indwelling catheters. The facility identified six residents with urinary catheters.

Inspectors wroteBased on observation, record review, review of nutritional formula information and interview the facility failed to provide the appropriate tube feeding to meet nutritional needs for one resident (Resident #475) and failed to timely address a significant weight loss for one resident (Resident #53). This affected two residents (#53 and #475) of four residents reviewed for nutrition. The facility identified four residents with feeding tubes and ten residents with unplanned significant weight changes.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #19's oxygen was delivered at the rate ordered and failed to notify the physician when the resident's rate of oxygen was increased. This affected one resident (#19) of two residents reviewed for respiratory care.

Inspectors wroteBased on record review, facility guidance review and interview the facility failed to ensure laboratory testing for Resident #33 was obtained as ordered. This affected one resident (#33) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on record review, review of Loeb Minimum Criteria for Initiating Antibiotic Therapy, review of the facility policy and procedure and interview the facility failed to ensure antibiotic use was appropriate to treat an infection for Resident #60. This affected one resident (#60) of five residents reviewed for unnecessary medication use.