Park Place Nursing & Rehabilitation Center

Inspectors wroteBased on interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 6 of 7 medication carts reviewed for pharmacy services [1st Floor MA Cart, 1st Floor Nurse West/North (Odd) Cart, 2nd Floor MA West/North (Odd) Cart, 2nd Floor MA East/North (Even) Cart, 2nd Floor Nurse West/North (Odd) Cart, 2nd Floor East/North (Even) Cart]). The facility failed to ensure the nursing staff responsible for the safekeeping of narcotics performed and documented change of shift narcotic counts for the 1st Floor MA Cart, 1st Floor Nurse West/North (Odd) Cart, 2nd Floor MA West/North (Odd) Cart, 2nd Floor MA East/North (Even) Cart, 2nd Floor Nurse West/North (Odd) Cart, and 2nd Floor East/North (Even) Cart. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 facility kitchens. The facility failed to ensure 3 cans of beets and 1 box of soybean frying shortening were not on the pantry floor. The facility failed to ensure stainless steel steam table pans were not stacked wetThe facility failed to ensure DA A did not hand dry items placed on the drain rack at the 3-compartment sink to air dryThe facility failed to ensure the bulk sugar bin did not have a scoop laying inside the product. These failures could place residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for six (Residents #56, # 36, #27, #12, #73, and #71) of six residents reviewed for physical environment. The facility failed to maintain clean, sanitary, and safe conditions in rooms for Residents #56, #36, #27, #12, #73, and #71 to prevent accident hazards. Specifically, the facility allowed dirt and debris to accumulate on flooring, rugs, and floor signs, and improperly stored an extra bed in a resident room, creating a trip hazard. These failures could place residents at risk of living in an unsafe, unsanitary and uncomfortable environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge in facility tracking record was electronically transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #85) reviewed for discharge MDS assessments. The facility failed to transmit a discharge MDS assessment for Resident #85. This failure could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 1 of 5 residents reviewed for resident assessments (Residents #75). The facility failed to ensure Resident #75 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness and refer the resident to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours for 1 of 5 residents (Resident #93) reviewed for care planning. The facility failed to develop a baseline care plan for Resident #93 within 48 hours of admission. This failure could place newly admitted residents at risk of delays in implementing individualized interventions necessary to address their immediate needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 5 residents (Resident #57) reviewed for quality of life. The facility failed to ensure Resident #57 received nail care as observed on 06/28/2026, 06/29/2026, and 06/30/2026. This failure could place residents who are dependent on staff assistance at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post their most recent survey of the facility in an area of the facility accessible to residents, and family members and legal representatives of residents. The facility also failed to have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request, in 1 of 1 facility reviewed for resident rights. 1. The facility failed to maintain the most recent standard survey results dated 4/4/2026 and 4/22/2026 inside the public survey binder.2. The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives. [...]

Inspectors wroteBased on observation and interview, the facility failed to post the daily nurse staffing data at the beginning of the shift, in a prominent place, and readily accessible to residents and visitors that included the facility name and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care for 12 of 14 days reviewed for nurse staffing data. The facility did not post the daily staffing on 06/17/2026, 06/18/2026, 06/19/2026, 06/20/2026, 06/21/2026, 06/22/2026, 06/23/2026, 06/24/2026, 06/25/2026, 06/26/2026, 06/27/2026, or 06/28/2026. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegations were made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for one of five residents (Resident #1) reviewed for injury of unknown origin. The facility failed to report an injury of unknown origin until 6 hours after the incident occurred. This failure could place residents at risk of not receiving timely investigation into allegations of injury of unknown origin.

Inspectors wroteBased on interview, and record review, the facility failed to provide or obtain necessary emergency dental services for 1 of 9 residents reviewed for dental services (Resident #1). The facility failed to timely complete and follow up on a dental referral after becoming aware of Resident #1's dental concerns on 3/3/26. The referral was not submitted until 3/12/26, resulting in the resident developing right-sided facial swelling, pain, and infection, requiring transfer to the emergency room on 3/12/26. This failure placed residents at risk for delayed dental treatment, increased pain, infection, and decline in condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the residents' practicable physical, mental, and psychosocial well-being for 3 (Resident #1, Resident #2, and Resident #3) of 6 residents reviewed for care plans. The facility failed to implement person-centered care plans for areas triggered on the CAA (Care Area Assessment) with interventions within 21 days of admission for Resident #1, Resident #2 and Resident #3 to meet medical, nursing, mental and psychosocial needs. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.

Inspectors wroteBased on interviews and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 1 of 4 residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure as of 10/20/25 Resident #1's WAR had been completed to reflect she had been receiving wound care to her BLE as ordered in October 2025. The facility failed to be able to identify the staff member who's initial in the EMR system were MP1 on Resident #1's WAR after it had been filled out for October 2025. These failures could place residents receiving wound care at risk for wound care to be done more often than ordered by the physician, for staff not being able to question or collaborate with the unidentified staff member, or for receiving inaccurate care or diagnoses due to lack of documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 staff (LVN B) viewed for infection control. The facility failed to ensure LVN B performed hand hygiene between glove changes while performing wound care on 10/22/25. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse for 1 of 4 residents reviewed for abuse. (Residents #1)The facility failed to ensure Resident #1 was free from physical abuse when on 05/02/25 Resident #2 grabbed Resident #1's shirt around the neck, stretching the fabric, and bit her hand. Resident #1 had a visible bite mark to the back of the left hand and redness to the chest. This failure could place residents at risk for emotional distress, fear, decreased quality of life, and further abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care within 48 hours of a resident's admission and provide the resident and their representative with a summary of the baseline care plan for 4 of 21 residents (Resident #4, #5, #12 and #15) reviewed for new admissions. 1. The facility did not provide a copy of the baseline care plan to Resident #4 or their representative. 2. The facility to develop and accurately complete a baseline care plan within 48 hours of admission for Resident #5, #12, and #15. This failure could lead to residents not receiving necessary care and decreased quality of life.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 7 of 21 residents (Resident #s 1, 8, 9, 10, 11, 12, and 14) reviewed for skin assessments. The facility failed to ensure Residents #1, #8, #9, #10, #11, #12, and #14 received a weekly skin assessment to identify risk of pressure injuries or existing pressure injuries. This failure could place residents at risk for developing unidentified pressure ulcers, could contribute to developing avoidable pressure ulcers and of not receiving adequate care and medical treatments to maintain skin integrity.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 3 medication carts (1st Floor North/East Medication Aide Cart, 1st Floor North (even)/East Nurse Cart, and 1st Floor North (odd)/West Nurse Cart) and 1 of 3 residents (Resident #3) reviewed for controlled medications.* LVN C did not sign out on Resident #3's narcotic count sheet for the hydrocodone/acetaminophen 5mg/325mg (narcotic pain medication) when she administered the medication on 11/19/25 or 11/20/25 during the night shift.* LVN C, RN B, and LVN D did not count the narcotics on the 1st Floor North/East Medication Aide Cart with during the [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency, for 1 (Resident #6) of 4 residents reviewed for reporting allegations of abuse. The facility failed to report an allegation of abuse within 2 hours to the State Agency when Resident #6 reported to PTA J he was left on the bedpan too long and felt like he was abused. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 4 residents (Resident #2) reviewed for MDS assessment accuracy. Resident #2's MDS admission assessment dated [DATE] failed to indicate Resident #2 had a pressure wound. This failure could place residents at risk of not receiving adequate care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 staff (CNA A) observed for infection control. The facility failed to ensure CNA A performed hand hygiene between glove changes. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: During an observation on 6/18/25 at 1:20 p.m. CNA A performed incontinent care on Resident #1. CNA A performed hand hygiene and put on gloves. CNA A opened Resident #1's wet brief. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 9 residents (Resident #1) reviewed for quality of care. 1. The facility failed to follow up with a cardiologist appointment on 2/25/25 for Resident #1 for 36 days, from 2/25/25 to 4/1/25. 2. The facility failed to ensure Resident #1 received a vascular surgeon referral when the order was given on 02/12/25, which resulted in the development of gas gangrene (rare but highly lethal and potentially life-threatening bacterial infection that destroys muscle tissue, blood cells, and blood vessels producing a gas that causes tissue death and a foul smell) and an above-the-knee amputation (surgical removal) of his right leg on 04/02/25. An immediate jeopardy (IJ) was identified on 05/04/25 at 11:00 AM. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene care for 3 of 19 residents (Resident #51, #44, and #86) reviewed for ADL care. The facility failed to ensure Resident #51 and #86 were provided with proper personal hygiene care. The facility failed to ensure showers were completed for Resident #44. This failure could place residents at risk of not receiving the care as needed and place them at higher risk for skin breakdown and to feel socially isolated and have a loss of dignity and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 27 residents (Resident #11) and 1 of carts (first-floor east hall) reviewed for medication pass and storage. The facility failed to administered calcium carbonate 750 mg-simethicone 250 mg chewable tablet (calcium carbonate/simethicone) two tablets to Resident # 11 on 04/29/25. The facility failed to remove expired medications from the first-floor east hall nurse cart. These failures could place residents at risk for not receiving the intended therapeutic response of prescribed medications and not having accurate records of medication administration which could result in diminished health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 1 residents reviewed for care plans. (Resident #86) The facility failed to revise Resident #86's Care Plan to reflect person centered interventions for tracheostomy care. This failure could place residents at risk of not having their needs addressed by nursing staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences, for 1 of 1 residents (Resident #86) reviewed for respiratory care. The facility failed to ensure Resident #86 had a replacement trach at bed side, suction catheters and a sterile kit for suctioning at bedside and there was no manual resuscitation bag. These failures could affect residents who were dependent on respiratory care and could contribute to upper respiratory infections and worsening of their physical condition.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #95) reviewed for Enhanced Barrier Precautions. CNA G failed to don PPE while assisting Resident #95 to transfer to his bed and adjusting his urinary catheter drainage bag. This failure could place residents under their care at risk for the transmission of communicable diseases and infections.

Inspectors wroteBased on interviews, observation and record review, the facility failed to maintain grooming and personal hygiene for 1 (Resident #2) of 1 resident reviewed for activities of daily living care. The facility failed to ensure grooming and personal hygiene care was provided to Resident #2 in a timely manner. This failure could place residents at risk for social isolation and a loss of dignity and self-worth.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of Resident #1 reviewed for pharmacy services. The facility failed to ensure RN A did not leave Resident #1's medications at bedside. This failure could place residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assure that Resident#1 received a therapeutic diet as prescribed by his physician. The facilty did not ensure Resident #1 received his physician ordered reduced concentrated sweets diet. The failure could place residents at risk for increase in disease process and other negative outcomes, such as wound healing, decline in functioning.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Residents #1, #2, and #3) reviewed for Enhanced Barrier Precautions. The facility failed to provide containers with clean PPE products and containers to discard used PPE on the halls or nearby the rooms of Residents #1, #2, and #3. CNA A and Corporate Regional RN failed to don PPE when they pulled Resident #1 up in bed. CNA E failed to don PPE while transferring Resident #3 on a mechanical lift, adjusting his urinary catheter drainage bag, or while assisting him to brush his teeth. [...]

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering, and receipt of all drugs and biologicals, to meet the needs of 1 of 6 (Resident #1) residents reviewed for pharmacy services. The facility failed to ensure Resident #1 received Sodium chloride 2000 mg every 8 hours, as indicated on his hospital after visit summary, from 03/05/24 through 07/24/24. Resident #1 was administered the incorrect dose of Sodium chloride 1000 mg every 8 hours (12:00 a.m., 8:00 a.m., and 4:00 p.m.) from 03/05/24 through 07/18/24 and from 07/20/24 through 07/24/24. Resident #1 was not administered Sodium chloride at 12:00 a.m. on 07/19/24. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on interviews and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for 1 of 1 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's RP was notified after she had a fall and sustained injuries. This failure could put residents at risk for a decreased quality of life.

Inspectors wroteBasedonobservation interview andrecordreviewthefacilityfailedtomaintainaclean safe comfortableandhomelikeenvironmentfordailylivingfor3 of3 (Resident#8, #21 and#59) reviewedforenvironmentalconditions(Resident#8, #21 and#59) reviewedforpersonalequipmentinthat Duringtheinitialobservationtourthefacilityfailedtomaintaincleanlinessofwheelchairsfrombeingcoveredwithfood dirt andgrayfuzzymatter. (Resident#8, #21 and#59). NursingstafffailedtocleanResident(Resident#8, #21 and#59) wheelchairasevidencedwithdriedfoodresidueonthearmrest ontheframeofthewheelchairsandonthespokesofbothwheels Thesefailurescouldaffectresidentswhoresideatthefacilityandusewheelchairsandcouldplacethematriskoflivinginanunsafe unclean uncomfortable andunhomelikeenvironment

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 (Resident #22) of 19 residents reviewed for ADLs. The facility failed to ensure showers were completed for Resident #22. Resident #22 received 11 of 23 scheduled showers, for the months of January 2024 and February 2024. This failure could affect the residents who require extensive assistance with care from facility staff by placing them at risk for social isolation, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care and services for the provision of parenteral fluids consistent with professional standards of practice for 1 of 1 residents (Resident #90) reviewed for parenteral fluids. The facility did not ensure Resident #90 received a peripheral intravenous catheter (PIVC - small tube inserted into a vein that allows for the administration of medications, fluids and/or blood products) dressing change per facility policy. This failure could affect residents by placing them at risk for infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for 3 of 3 meals (Lunch meal on 02/26/24 and 02/27/24 and breakfast on 02/27/24) observed for frequency of meals. (Residents #9, #25, #26, #55, #59, #90, and #99) The facility did not serve the 02/26/24 lunch meal, the 02/27/24 breakfast meal and the 02/27/24 lunch meal at the scheduled times. Residents #9, #25, #26, #55, #59, #90, and #99 did not receive their meals during the regular mealtimes. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medication given without food, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. One 50 pound bag of powdered milk in the pantry was open and not sealed. Stainless steel pans and full-size baking sheets were stacked wet on the pan rack Hot food items holding for service were not re-heated to the appropriate temperatures before service. These failures could place residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 4 residents reviewed for nutritional status (Resident #55). The facility failed to ensure Resident #55 did not have a significant weight loss in 30 days for the months of January and February 2024. The facility failed to ensure Resident #55 consistently received a frozen dietary supplement as prescribed by the physician for 13 of 27 evening meals in February 2024. These failures could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life.