Park Lane Nursing Home

Inspectors wroteThe facility identified a census of 35 residents, including five residents with full code status, and six residents sampled for code status. Based on record review and interview, the facility failed to ensure staff provided cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) to Resident (R) 1, who desired resuscitative measures as indicated by his full code status. Around 09:00 PM on [DATE], Certified Nurse Aide (CNA) M saw R1's representative leave his room. At 09:50 PM, CNA M entered R1's room and noted the resident was purple and lacked a pulse. CNA M called on the radio he needed a nurse STAT (immediately) and then stepped out of R1's room and shut the door. CNA M was not aware R1 was a full code status. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents, with five residents reviewed for immunizations. Based on record review and interview the facility failed to ensure that Resident (R) 8, R5, R19, R23, and R24 were offered and educated regarding the Prevnar 20 (PCV20) pneumococcal (type of bacterial infection) vaccination (a pneumococcal conjugate vaccine that protects against 20 different strains of pneumonia) or assessed and deemed contraindicated as recommended by the Centers for Disease Control and Prevention (CDC). This deficient practice placed these residents at risk of acquiring, transmitting, or experiencing complications from pneumococcal disease.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents. Based on record review and interview, the facility failed to provide Resident (R) 3, R14, and R36 or their representative, the completed Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) Form 10055. This placed the resident at risk of uninformed decisions about their skilled services.

Inspectors wroteThe facility identified a census of 37 residents. Based on interviews and record review, the facility failed to conduct a criminal background check as required for one facility employee. The employee was allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This deficient practice placed the affected residents at risk for abuse, neglect, misappropriation, or mistreatment.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to notify the Long Term Care Ombudsman (LTCO) for Resident (R) 8's and R4's facility-initiated discharge to the hospital. This deficient practice placed R8 and R4 at risk for impaired rights.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents, with two residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R) 8 and R4 with written information regarding the facility bed hold policy when she was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents with two reviewed for accidents. Based on observation, interview, and record review the facility failed to thoroughly investigate the causative factor to prevent further falls for Resident (R)1 after she slid out of her wheelchair. This deficient practice placed R1 at risk for injuries related to falls. The facility failed to promote an environment free of hazards for Resident (R) 6 who smoked cigarettes but lacked a smoking assessment since admission to the facility. This placed the resident at risk for avoidable injuries and fire-related hazards

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents, with five reviewed for unnecessary medication. Based on observation, interview, and record review, the facility's consultant Pharmacist failed to obtain an approved indication for use for Seroquel (antipsychotic -class of medications used to treat psychosis and other mental-emotional conditions) for Residents (R) 23, R24, and Zyprexa (antipsychotic) for R15 This deficient practice placed the three residents at risk to receive unnecessary antipsychotic drugs.

Inspectors wrote- R15's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with mood and behavioral disturbance, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and cellulitis (skin infection caused by bacteria). R15's Annual Minimum Data Set (MDS) date 07/12/24 documented she was unable to recall the current season, the location of her room, any staff names, or faces, or that she was in a nursing facility. R15 displayed physical behavioral symptoms directed toward others on one to three days during the look-back period. R15 was dependent on staff for all functional abilities and activities of daily living (ADL). [...]

Inspectors wroteThe facility had a census of 46 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide a dignified dining experience for Resident (R) 8, placing the resident at risk for impaired wellbeing.

Inspectors wroteThe facility had a census of 46 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide interventions for lack of bowel movements for one Resident (R) 36, who had a history of constipation (difficulty in emptying the bowels). This placed the resident at risk for impaction (the condition of being or process of becoming impacted, especially of feces in the intestine).

Inspectors wroteThe facility had a census of 46 residents. The sample included 12 residents, with one reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to prevent the development of one facility acquired pressure ulcer for Resident (R) 38, who acquired a Stage 2 pressure ulcer (shallow with a reddish base and have a break in the top two layers of skin). The facility failed to implement interventions which included nutritional consults to promote optimal healing and prevent worsening of skin breakdown for R38. This placed the resident at risk for further breakdown.

Inspectors wroteThe facility had a census of 46 residents. The sample included 12 residents, with 10 reviewed for falls. Based on observation, record review, ad interview, the facility failed to provide a safe environment and failed to follow the care plan for two sampled residents, Resident (R) 36 and R38. This placed the resident's at risk for further falls and injury.

Inspectors wroteThe facility had a census of 46 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Pharmacist Consultant identified and reported the lack of an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)39 and R38. This placed the residents at risk for unnecessary psychotropic (altering mood or thought) medication use and related consequences.

Inspectors wroteThe facility had a census of 46 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to provide an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for resident (R)39 and R38. This placed the residents at risk for unnecessary psychotropic ( altering mood or thought) medication use and related consequences.

Inspectors wroteThe facility had a census of 43 residents. The sample included 13 residents. Based on interview and record review, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan (a written plan containing the process that would guide the nursing homes efforts in assuring care and services were maintained at acceptable levels of performance and continually improved).

Inspectors wroteThe facility had a census of 43 residents. The sample included 13 residents with six reviewed for unnecessary medications. Based on observation, interview, and record review the facility's consultant pharmacist failed to notify the Director of Nursing, medical director, or the residents' physicians regarding six of six sampled residents' PRN (as needed) psychotropic medications (chemical substance that changes nervous system function and results in alterations in perception, mood, consciousness, cognition, or behavior) lacked a required stop date, Resident (R) 26, R32, R10, and R33.

Inspectors wrote- Resident (R) 10's Physician Order Sheet (POS), dated 09/08/21, documented diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) with psychotic features, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychotic disorder (mental disorder characterized by a gross impairment in reality testing) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavior disturbance. [...]

Inspectors wroteThe facility had a census of 43 residents. Based on observation, record review, and interview, the facility failed to employ a full time certified dietary manager for 43 residents who resided in the facility and received meals from the facility kitchen.