Park Terrace Care Center

Inspectors wroteBased on observation, record review, and interviews, during the Recertification and Abbreviated Survey (Intake #797338), the facility failed to provide a clean, comfortable and homelike environment for the residents. Specifically, housekeeping and maintenance services were not maintained in Unit 4.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding. This was evident for three (3) (Residents #137, #41, and #52) out of 25 residents reviewed for medication administration task. Specifically, licensed nurses did not appropriately verify placement of gastrostomy tube prior to administering medications and enteral feeding.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure physicians reviewed the residents' total program of care. This was evident for two (2) (Residents #107 and #184) of three (3) residents reviewed out of 40 total sampled residents. Specifically, the physician's progress notes did not accurately reflect the residents' total care plan and current condition.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This was evident during the Kitchen task and during meal pass observation. Specifically, 1.) Expired food items were observed in the kitchen. 2.) Kitchen staff were observed without beard restraint while preparing food in the kitchen. 3.) Food was not in acceptable temperature range. 4.) Egg salad, ham, and tuna sandwiches were stored at room temperature in Unit 4 and Unit 6. 5.) Certified Nursing Assistant #3 failed to perform hand hygiene while assisting residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was evident during kitchen observation and in five (5) (Units 2, 3, 4, 5 and 6) of five (5) units observed. Specifically, ripped chairs were observed in the dining rooms in all units, dust accumulations were observed in the kitchen, and dirty floors and walls were observed in Unit 4, along with corroded metal cabinet.

Inspectors wroteBased on observation, record review, and interviews, during the Recertification and Abbreviated Survey (Intake #797338), the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. This was evident for one (1) (Unit 4) of 5 floors and the kitchen. Specifically, multiple reports of roach and rodent sightings were made by staff and residents. Additionally, a roach was observed crawling on top of the dish machine during kitchen observation.

Inspectors wroteBased on record review and interviews during the Recertification and Abbreviated Survey (Intake #797338), the facility failed to ensure Resident #199's representative was informed about a bed bug infestation in the resident's room. This was evident for one (1) (Resident #199) of one (1) resident reviewed for Notification of Change out of 40 total sampled residents.

Inspectors wroteBased on record reviews and interviews during the Recertification survey conducted from 08/24/2023 to 08/31/2023, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was evident for Resident #144 reviewed out of a sample of 37 residents. Specifically, after admission to the facility, the resident developed a new left buttock pressure ulcer, which worsened and became infected requiring the resident to be admitted to the hospital. There was no evidence the wound was evaluated between identification as an excoriation on 03/06/23 and becoming an unstageable ulcer on 3/21/2023. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 8/24/23 through 8/31/23, the facility did not ensure an Infection Preventionist (IP) with specialized training was designated to be responsible for the facility's Infection Prevention and Control Program (IPCP). This was evident during the review of the Infection Control Task. Specifically, the facility's designated IP did not have documented evidence of completing specialized infection prevention and control training.

Inspectors wroteBased on observations, record review and interview conducted during the recertification survey from 8/24/23 to 8/31/23, the facility did not ensure that the results of the most recent survey report and plan of correction of the facility was posted in a place readily accessible to residents, and family members and legal representatives of residents. Specifically, the survey report was posted at an elevated level, in a locked glass case on the wall opposite the main lobby elevators. This was evident for 12 of 12 attendees of the Resident Council meeting.

Inspectors wroteBased on observations and interviews conducted during a Recertification survey conducted from 08/24/23 to 8/31/2023, the facility did not ensure that proper sanitation and food handling practices were conducted to prevent potential foodborne illnesses. Specifically, 1) portions of the meat slicer were washed and sanitized but replaced on the machine with ungloved hands and 2) unlabeled, undated food and staff food was observed stored in a pantry refrigerator on a resident unit (Unit 4).

Inspectors wroteBased on observations and interviews during the recertification survey from 8/24/23 through 8/31/23, the facility did not ensure that garbage was disposed of properly. Specifically, the trash bin was not covered when being transported from the kitchen and the trash was placed in an uncovered and unlocked dumpster.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 8/24/2023 to 8/31/2023, the facility did not ensure the resident's right to a dignified existence. This was evident for 3 (Resident #28, #45, and #135) out of 54 total sampled residents. Specifically, 1) Residents #28 and #135 were fed by staff standing over them, and 2) staff placed clothing protectors on Resident #45 without asking permission.

Inspectors wroteBased on record review and staff interview conducted during the Recertification survey from 8/24/2023 to 8/31/2023 the facility did not ensure that a resident Comprehensive Care Plan was reviewed and revised as needed with interventions to reflect the resident's changing needs. This was evident for 1 (Resident #162) of 4 residents reviewed for Accidents out of a sample of 54 residents. Specifically, Resident #162's Fall CCP was not revised with new interventions after a fall while Resident #162 was trying to use the bathroom.

Inspectors wroteBased on record review, observation and interview conducted during the Recertification survey from 8/24/23 to 8/31/23, the facility did not ensure that services provided met professional standards of quality care. Specifically, blood pressure was not taken before a resident was administered blood pressure medication to ensure it was within the parameters to safely administer medication as ordered by the physician. This was observed during the Medication Administration Task. (Resident #145)

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey conducted from 8/24/23 through 8/31/23, the facility did not ensure residents who could not carry out Activities of Daily Living (ADL) received the necessary services to maintain good nutrition. This was evident for 1 of 4 residents (Resident #153) out of a sample of 54 residents reviewed. Specifically, Resident #153, who requires assistance with meals, was not assisted with their meals.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 8/24/23 to 8/31/23, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 2 of 5 residents reviewed for Limited Range of Motion out of 37 sampled residents (Resident #77). Specifically, 1) Resident #77 had bilateral upper extremity contractures and was observed without resting hand splints or elbow splints when out of bed and without hand rolls and soft elbow splints when in bed as per Medical Doctor Order (MDO), and 2) Resident #12 with a right-hand contracture was not provided with a splint device as per Medical Doctor Orders.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 8/24/23 through 8/31/23, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for 1 out of 2 residents reviewed for respiratory care out of 54 sampled residents (Resident #173). Specifically, Resident #173 was observed using oxygen via trach collar with no label on the tube.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 8/24/23 to 8/31/23, the facility did not ensure that the resident records were accurately documented in accordance with professional standards of practice. This was evident for 2 residents (Resident #153 and # 145) Specifically, 1) the Resident CNA Documentation History Detail dated 8/28/23 documented that Resident #153 ate 100% and drank 100% liquids for breakfast and lunch while the tray was observed at the bedside untouched, and 2) the Licensed Practical Nurse (LPN) documented a blood pressure reading for Resident #145 without assessing the resident's blood pressure.

Inspectors wroteBased on observation, record reviews and interviews conducted during the Recertification survey from 8/24/23-8/31/23, the facility did not ensure that infection control practices and procedures were maintained to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, while performing wound care for Resident #241 Registered Nurse (RN) #2 was observed not performing hand hygiene before and during wound care, failed to perform hand hygiene multiple times when changing gloves, and failed to set-up a sterile field and prepare supplies according to professional standards.

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey from 05/18/2022 to 05/26/2022, the facility did not ensure that a resident was cared for in a manner that maintained their dignity. This was evident for 1 (Resident #86) of 2 residents reviewed for Dignity. Specifically, Resident #86's Foley catheter (FC) bag and tubing were left uncovered and exposed to public view.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 5/18/22 to 5/26/22, the facility did not ensure a resident remained free from physical restraints. This was evident for 1 (Resident #48) of 4 residents reviewed for Restraints. Specifically, Resident #48 was observed on several occasions with a wheelchair seatbelt (SB) without a Medical Doctor Order (MDO).

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure assessments accurately reflected the resident's status for 2 (Resident #s 104 and 140) of 40 sampled residents. Specifically, the Minimum Data Set 3.0 (MDS) assessments did not document the use of a wander guard device for Resident #104 and Resident #140.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint survey from 5/18/2022 to 5/26/2022, the facility did not ensure, to the extent practicable, that residents were involved in developing the comprehensive care plan and making decisions about their care. Specifically, the facility did not ensure that residents were afforded the opportunity to participate in the Comprehensive Care Plan (CCP) meeting. This was evident for 2 of 2 residents reviewed for Participation in Care Planning out of a sample of 40 residents (Resident # 42 and Resident # 48).

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey from 5/18/2022 to 5/26/2022, the facility did not ensure all drugs and biologicals are used and labeled in accordance with professional standards. This was evident for 1 (Unit 5) of 12 units observed for Medication Storage. Specifically, five expired medications were observed in the medication room and medication cart.