Park Nursing Home

Inspectors wroteBased on observations, record review, and interviews, the facility failed to update the electronic medical record with a resident's Medical Order for Life-Sustaining Treatment (MOLST) after returning to the facility from a hospitalization. This was evident for one (1) out of six (6) residents (Resident #1) reviewed for advanced directives. Specifically, Resident #1 had a Do Not Resuscitate (DNR)/ Do Not Intubate (DNI) order in place dated [DATE]. On [DATE], the resident was hospitalized and returned to the facility on [DATE]. On [DATE] at 9:47 PM, Resident #1 was found to be unresponsive. [...]

Inspectors wroteBased on interview and record review conducted during the survey, the facility failed to maintain medical records on each resident that are complete, accurately documented, and readily accessible and systematically organized. This was evident for one (1) of six (6) residents reviewed for Advanced Directive. Specifically, Resident #1 had Do Not Resuscitate (DNR)/ Do Not Intubate (DNI) order in place dated [DATE]. On [DATE] the resident was hospitalized and returned to the facility on [DATE]. On [DATE] at 9:47 PM, Resident #1 was found to be unresponsive. [...]

Inspectors wroteBased on observation and staff interviews during the Recertification survey it was determined that the facility did not ensure that the maintenance and housekeeping services provided, were maintained a sanitary, orderly, and comfortable interior on two (3S, 3N) of five resident units. This was evidenced by soiled, stained, torn, or broken furniture, dusty and soiled air conditioners, soiled, stained torn wallpaper, stained ceiling tiles, resident sinks and corridor bathrooms in disrepair, soiled torn clean linen cart covers.

Inspectors wroteBased on observations, record review, and interviews during the Recertification survey, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. This was evident for 2 (Elevator A and Elevator B) of 2 elevators. Specifically, during the Resident Council meeting, nine of nine residents complained of frequent elevator breakdowns. In addition, during the Recertification survey, the elevators were observed to shake, rattle, and bounce during use. The finding is:The facility policy titled Elevator Policy dated 12/10/2024 stated the purpose of this policy is to ensure the safe and proper operation of the elevators and to conform to regarding inspection and maintenance of elevators to ensure resident, staff and guest safety. [...]

Inspectors wroteBased on observations, interviews, and record reviews during the Recertification survey, the facility did not ensure that an effective pest control program was in place. This was evident for one (Unit 3 N) of five units and the 1st Floor Conference Room. Specifically, multiple flies, gnats, and roaches were observed during the initial and subsequent tours of the Pantry Room, corridors, resident bathrooms, and Nurse Station on Unit 3 N and the 1st floor Conference Room. The finding is: The facility policy titled Procedure in the event of Pest Sightings or Complaints dated 04/23/24 stated the facility is to ensure residents environment is clean, safe and pest free. All staff to document of sightings of pest in the pest book. The following observations of Unit 3N were made on 08/19/2025 at 10:40 AM, 08/20/2025 at 9:15 AM, and 08/26/2025 at 09:00 AM and at other times throughout the survey: [...]

Inspectors wroteBased on observation, record review, and interview conducted during an Abbreviated survey (NY00335621), the facility failed to provide adequate supervision to a resident to prevent an accident. This was evident in 1 out of 6 residents (Resident #3) sampled for accidents. Specifically, on 03/11/24 at 9:50 am Resident #3 was assisted into a bathroom toilet stall by Certified Nursing Assistant #3, who was assigned to provide 1:1 monitoring of Resident #3. At 10:35 am, Resident #3 exited from the toilet stall and was noted with a linear laceration measuring 1 centimeter above their left eye. Subsequently, Resident #3 was transferred to the hospital on [DATE] at 12:12 pm and was diagnosed with a Left Proximal Humerus Fracture (breaking the bone in the upper arm). This resulted in actual harm to Resident #3 that was not Immediate Jeopardy.

Inspectors wroteBased on observations, interviews, and record review during the Abbreviated Survey (NY00337011), the facility failed to protect residents' rights to be free from physical and verbal abuse by nursing home staff. This was evident in 2 out of 6 residents (Resident #1 and Resident #2) reviewed for abuse. Specifically, 1) On 03/25/24 between 5:00 am and 6:00 am, Certified Nurse Assistant #1 reported that they witnessed Certified Nursing Assistant #2 hit Resident #1 on their left cheek with a closed fit and used profanity at Resident #1 on 03/24/24 during care between 4:00 am and 5:00 am. 2) Certified Nursing Assistant #1 also reported on 03/25/24 at 8:00 am that they witnessed Certified Nursing Assistant #2 roughly washed Resident #2's testicle and hit Resident #2 on their hand with a lotion bottle during peri-care on 03/24/24 between 4:00 am and 5:00 am.

Inspectors wroteF609 S/S E Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00337011), the facility failed to ensure that an alleged violation involving abuse was reported immediately but not later than two hours after the allegation was made if the events that caused the allegation involve abuse or result in serious bodily injury to New York State Department of Health and to local law enforcement. This was evident in 2 out of 6 residents reviewed for abuse (Resident #1 and Resident #2). Specifically, 1) On 03/25/24 between 5:00 am and 6:00 am, Certified Nurse Assistant #1 reported that they witnessed Certified Nursing Assistant #2 hit Resident #1 on their left cheek with a closed fit and used profanity at Resident #1 on 03/24/24 during care between 4:00 am and 5:00 am. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during an Abbreviated Survey (NY00337011), the facility failed to ensure that a care plan was reviewed and revised by the interdisciplinary team after each assessment. This was evident in 2 out of 6 residents sampled (Resident #1 and Resident #2). Specifically, 1) On 03/25/24 between 5:00 am and 6:00 am, Certified Nurse Assistant #1 reported that they witnessed Certified Nursing Assistant #2 hit Resident #1 on their left cheek with a closed fit and used profanity at Resident #1 on 03/24/24 during care between 4:00 am and 5:00 am. Resident #1's care plan was not reviewed and revised to reflect the allegation of abuse. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during an Abbreviated Survey (NY00337011), the facility failed to maintain clinical records that are complete and accurately documented in accordance with accepted professional standards and practices. This was evident in 2 out of 6 residents (Resident #1 and Resident #2) reviewed for Abuse. Specifically, on 03/25/24, Certified Nurse Assistant #1 reported that they witnessed Certified Nurse Assistant #2 being verbally and physically abusive to Resident #1 and Resident #2. There were no assessments documented in Resident #1 and Resident #2's medical records prior to New York State Department of Health Surveyor's onsite visit on 04/02/24. Additionally, there were no physician's assessments documented in Resident #1 and Resident #2's medical record.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 10/26/2023 to 11/2/2023, the facility did not ensure accuracy of resident assessments. This was evident for 2 (Resident #100 and #170) of 36 total sampled residents. Specifically, 1) Resident #100's Minimum Data Set 3.0 (MDS) assessment did not document the resident's diagnosis of schizophrenia and depression, and 2) the Minimum Data Set 3.0 (MDS) assessment for Resident #170 documented the resident's planned discharge as an unplanned discharge.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 10/26/2023 to 11/2/2023, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #121) of 9 residents reviewed for accidents out of 36 total sampled residents. Specifically, Resident #121 was observed without a soft helmet in place when out of bed in accordance with Physician's Order (PO).

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification and Complaint (NY00321629) survey from 10/26/2023 to 11/02/2023, the facility did not ensure that a resident was free from misappropriate of property. This was evident for 1 (Resident #77) of 9 residents reviewed for abuse out of 36 total sampled residents. Specifically, a Home Health Aide (HHA) employed by the facility used Resident #77's bank card to purchase items totaling $1100.00.

Inspectors wroteBased on interview and record review conducted during the recertification and complaint (NY00321227) survey from 10/26/2023 to 11/2/2023, the facility did not ensure that an alleged violation involving abuse was reported immediately, but not later than 2 hours after the allegations were made to the New York State Department of Health (NYSDOH). This was evident for 2 (Resident #46 and Resident #6) of 9 residents reviewed for abuse out of 36 total sampled residents. Specifically, an altercation involving Resident #46 and Resident #6 was not reported to the NYSDOH within 2 hours of the occurrence.

Inspectors wroteBased on observation and staff interviews conducted during the Recertification survey, the facility did not ensure that the daily staffing was posted in a prominent place readily accessible to residents and visitors. Specifically, daily nursing staffing was not observed to be posted on 4 separate occasions.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure safe food handling and storage was practiced to prevent food-borne illness. Specifically, expired food was found stored in the kitchen freezer and the emergency food storage area. This was evident during the Kitchen Observation task.

Inspectors wroteBased on observations, record review, and staff interviews during the recertification survey, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) oxygen tubing was observed on multiple occasions touching the floor; and, 2) staff were observed not performing hand hygiene during dining in between assisting residents. This was evident for 1 of 4 residents observed for Respiratory Care (Resident #155) and 1 out of 5 units observed for dining (Residents # 36, #78, #92 and #125) on unit # 2 out of an investigative sample of 40 residents.

Inspectors wroteBased on observation, record review and interview conducted during a Recertification survey, the facility did not ensure residents' rooms were maintained in a homelike environment. Specifically, five rooms on the second and one room on the third floor were noted with air conditioning (AC) units with gray colored dust buildup in the filters and brown/black spots on the grates. This was evident for 2 out of 5 floors observed for the Environment.

Inspectors wroteBased on observation, record review and interview during the Recertification survey conducted from 9/15/21 to 9/22/21, the facility did not ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Specifically, a resident was observed on more than one occasion over 6 days to have fingernails approximately quarter inch from the tip of the fingers. This was evident for 1 of 3 residents reviewed for Activities of Daily Living out of a sample of 40 residents. (Resident # 324). The finding is: The facility Policy & Procedure titled Resident Hygiene and Daily Care with effective date 05/21/2021 documented Residents will be provided with or assisted with daily hygiene and care in-order to promote dignity and wellness. [...]

Inspectors wroteBased on observation, record review, and staff interview during the Recertification survey conducted from 9/15/21 to 9/22/21, the facility did not ensure an ongoing program of activities was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident based on the comprehensive assessment and care plan. Specifically, a resident with major depressive disorder was observed for extended periods of time without meaningful activities. This was evident for 1 of 2 residents reviewed for Activities out of 40 sampled residents (Resident # 46). The finding is: [...]

Inspectors wroteResident #122 Based on observations, record reviews and interviews conducted during the recertification survey, the facility did not ensure a resident with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. Specifically, a resident with a Foley Catheter in place had no documented evidence that Foley Care was provided. This was evident of 1 out of 2 residents investigated for Urinary Catheter, out of an investigative sample of 40 residents, (Resident #122).