Park Manor Ltd

Inspectors wroteBased on record review and interviews, the facility did not ensure that an alleged violation involving abuse was reported to the State Survey (SA) and law enforcement. This had the potential to affect 1 of 4 residents (R1) investigated for abuse. The facility reported the incident to the SA within five days following their investigation, but did not report the injury of unknown origin to the SA within 24 hours. Surveyor reviewed the facility's policy titled Abuse and Misconduct, which read in part, The administrator, Director of Social Services, and/or the Director of Nursing determined whether the suspicion/alleged incident is reportable (meets the definition of caregiver misconduct) to the Division of Quality Assurance and other officials. On 06/20/26, the facility submitted an alleged nursing home resident mistreatment, neglect, and abuse report to the State Agency (SA). [...]

Inspectors wroteBased on Interview and record review, the facility did not ensure that all alleged violations involving abuse resulting in physical harm, pain or mental anguish are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility (including to the State Survey Agency) and to other officials in accordance with State law through established procedures for 2 (R5, R8) of 6 residents. On 4/16/26 at 8:15 AM, R6 barricaded self in R5's room and threatened to harm R5. The facility did not report this within allotted time frames. On 6/4/25 at approximately 7:40 AM, Certified Nursing Assistant (CNA) D heard Registered Nurse (RN) E yelling at R8. This was not reported within allotted time frames.

Inspectors wroteBased on interview and record review the facility did not complete a thorough investigation regarding potential verbal and psychosocial abuse for 1 of 6 residents reviewed (R8),-The facility did not remove the accused staff member from the facility pending investigation-All present parties to the incident were not interviewed

Inspectors wroteBased on record review and interview, the facility did not provide Notice of Bedhold and Notice of Transfer to a resident or resident representative who were transferred from the facility to a hospital for 4 of 4 residents (R) (R4, R20, R33 and R34). Example 1 R4 was admitted to the facility on [DATE] and has an Activated Power of Attorney (APOA). On 06/11/25, R4 had a change in condition that required being sent to emergency room (ER). The facility contacted R4's APOA and left a voicemail regarding change in condition. The facility was unable to provide documentation to support that the APOA was provided a Notice of Bedhold or Notice of Transfer. On 07/08/25, R4 had a change in condition that required being sent to emergency room (ER) and subsequently admitted to hospital. The facility contacted R4's APOA who gave consent to send to hospital. [...]

Inspectors wroteBased on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for 4 residents (R) (R43, R25, R35 and R34) of 18 sampled residents.

Inspectors wroteBased on interview and record review, the facility did not develop a comprehensive person-centered care plan for 2 of 18 sampled residents (R46 and R60). The facility did not develop a care plan for R46 and R60 for respiratory care.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure care plans were reviewed and revised to reflect changes in care for 2 of 18 residents (R45 and R6). According to the Resident Assessment Instrument, The comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. The facility policy entitled Comprehensive Person-Centered Care Planning and last reviewed on 05/15/24 with a Policy Statement: [...]

Inspectors wroteBased on observation, record review and interview, the facility did not implement enhanced barrier precautions consistent with current infection control standards of practice for 1 of 3 residents reviewed on enhanced barrier precautions (R29). This is evidenced by: Surveyor requested and reviewed the facility policy titled Infection Prevention and Control dated as most recently reviewed on 2/20/2023. The policy in part read: Standards of Practice: Centers of Disease Control (CDC) Association for Professionals in Infection Control (APIC) Enhanced Barrier Precautions Implementation of Personal Protective Equipment in Nursing Homes to Prevent the Spread of Novel or Targeted Multi-Drug-resistant Organisms (MDRO's) updated: July 29, 2019. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 of 3 residents reviewed for falls had adequate supervision and assistance to prevent accidents. A thorough fall investigation was not completed to determine staff used a mechanical lift with 1 assist for (R1), This is evidenced by: Surveyor reviewed facility's undated policy titled Falls - Clinical Protocol, which read in part: 2. LPN's [Licensed Practical Nurse] should alert the supervisor (RN). The nurse will complete an assessment .5. Incident Scene Investigation (ISI) tool completed by staff who found resident, or who was present at the time - as completely as possible and as soon as possible but definitely before that person shift ends .7. If an LPN is the charge nurse, supervisor (RN) should review and follow up LPN documentation with their assessment of any problems or injuries . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish and implement an ongoing infection prevention and control program to prevent and control the onset and spread of infection to the extent possible as evidenced by the cumulative failures of the following 5 observations. Staff did not practice appropriate donning of Personal Protective Equipment (PPE) and hand hygiene with the care and services of a resident in Transmission-Based Precautions (TBP) for Clostridium difficile (R55), a very contagious bacterium. Staff did not practice appropriate hand hygiene with a dressing change for R179. Staff did not practice appropriate hand hygiene after incontinence cares with R44. Staff did not ensure 2 of 4 residents (R1 and R58) were given the opportunity to wash their hands prior to meal service. This is evidenced by: [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) received necessary services to maintain good nutrition for 2 of 3 sampled residents (R37 and R65). R37 prefers to eat in his room and requires staff assistance. Staff did not provide a breakfast tray or assistance for R37. R65 was not assisted with meal while repeatedly making attempts to reach food bowls that were placed out of her reach. This is evidenced by: Example 1 R37 was admitted to facility on 1/29/20. Diagnoses include right side paralysis after stroke, major depressive disorder, type 2 diabetes with insulin use, and dehydration. R37's care plan, dated 6/15/23, indicated R37 has a self-care deficit requiring assist of 1:1 with eating, staff to encourage intake. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 3 of 7 residents (R65, R15 and R58) reviewed for risk of pressure injury development, received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. R65 was observed on three occasions in which there was no repositioning offered for extended periods of time. R15 was observed on two occasions in which repositioning and toileting was not completed. R58 was observed on two occasions in which staff did not reposition or toilet. This is evidenced by: According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility did not ensure 3 of 10 residents reviewed for bowel and bladder incontinence or indwelling Foley catheters (R65, R37 and R15) received appropriate treatment and services to prevent Urinary Tract Infections (UTI) and to restore continence to the extent possible. -R65 was observed for extended periods of time on three separate occasions in which staff did not offer or attempt toileting services. -R37 has an indwelling Foley catheter with orders to change every month. There is no documentation to support routine change of R37's catheter. -R15 was observed on two separate occasions for extended periods of time in which toileting assistance was not provided. This is evidenced by: Acello, [NAME] RN MSN. The Long-Term Care Nursing Desk Reference. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that prior to the installation or use of bed rails, the facility attempted to use alternatives, ensure the resident is assessed for the use of bed rails, which includes a review of risks including entrapment; and informed consent is obtained from the resident or if applicable, the resident representative for 1 of 1 resident (R) R15. The facility did not ensure the grab bars are appropriate for R15, assess risk of entrapment versus benefit, and did not obtain consent from representative. This is evidenced by: R15 was admitted to facility on 10/32/22 and has diagnosis that include diagnosis of dementia with behavior disturbances and Parkinson's disease. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. This occurred for 1 of 3 residents, R11. RN C left R11's 8:00 am medications on his bed side table. R11 was not cognitively able to ensure administration of medications. Findings Include: On 07/18/23 10:10 a.m., Surveyor observed R11 in bed with his bedside table in front of his bed. On the table was a medication cup with 7 pills in the cup. Surveyor asked R11 about the medications and R11 responded, I don't know what the hell they are. Surveyor reported to nurses station and spoke with Registered Nurse (RN) C about the observation. RN C indicated she had left the pills on R11's bedside table at approximately 8:45 a.m. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 of 5 residents (R37) reviewed for antibiotic medications. R37 had five urinary tract infections (UTIs) in three months. R37 did not meet criteria to determine infection. R37 was prescribed antibiotic therapy prior to laboratory test results. R37 was treated with an antibiotic that laboratory tests confirmed was resistant. This is evidenced by: The facility's Antibiotic Stewardship Policy and Procedure, documents, in part: Antibiotic Stewardship Program (ASP) is established to ensure that a resident who needs an antibiotic receives the appropriate antibiotic and to reduce the risk of antibiotic resistance. Nursing staff will use established methods to communicate with physician when an infection is suspected. [...]

Inspectors wroteBased on interview and record review, the facility must ensure that a resident is free of any significant medication errors for 1 of 1 resident (R60) reviewed. The facility did not ensure R60 was administered insulin on three separate occasions as ordered from physician. This is evidenced by: The facility policy, entitled Medication Administration, dated 04/03/23, states: Medications are administered in accordance with prescriber orders, including any required time frame. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering should mark the reason in the MAR when signing out medications. R60 was readmitted to the facility on [DATE] and has diagnoses of diabetes mellitus. R60 has physician orders for insulin aspart 18 units three times a day at 7:30 am 11:30 am, and 4:30 pm for type 2 diabetes mellitus. Administration Instructions: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident (R) is offered a pneumococcal immunization for 1 (R11) of 5 residents reviewed for immunizations. R11's medical record did not contain documentation of R11 being screened and offered pneumococcal vaccine.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure nurse staffing information postings were displayed daily in a clear and readable format and in a prominent place readily accessible to residents and visitors. This had the opportunity to affect all 75 of 75 residents at the facility. The facility did not post nurse staffing information daily and the postings were not posted in a way that would be accessible to all residents and visitors. The facility did not create a nurse staffing information post that was clear and readable. This is evidenced by: On 07/17/23 at 9:19 AM, Surveyor observed that the nurse staffing information posting on the bulletin board down the 300 wing is dated July 10, 2023. The nurse staffing information posting is located approximately six feet from the floor. Surveyor observed that the font of the posting is small and hard to read. [...]