Park View Nursing Care Center

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 (Resident #1 and Resident #2) of 5 residents reviewed for abuse/neglect policy implementation. The facility failed to implement their abuse policy and report to state within 2 hours when Resident #2's family member alleged to RN F that Resident #1 entered Resident #2's room and hit her in the face on the evening of 03/19/26. This failure could place residents at risk of abuse and neglect occurring and/or continuing. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are 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, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 [...]

Inspectors wroteBased on interview, and record review 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 1 (Resident #3) of 5 residents reviewed for medication administration. The facility failed to ensure LVN B administered Resident #3's morning medications within an hour of the ordered time on 03/29/26. This failure could place residents at risk of increased disease symptoms and/or diminished quality of life. [...]

Inspectors wroteBased on interviews and record review, the facility failed to establish and maintain an effective system of accounting and record keeping according to generally accepted accounting systems, for 2 of 5 residents (Resident #1, 2) reviewed for trust fund accounting. The facility failed to: Ensure residents with a trust fund were given a full and complete recording of their trust fund transactions when requested (Resident #1)Maintain an accurate running ledger for each resident (Resident #1 and #2)Ensure residents were provided with a financial record of purchases and a quarterly statement at least quarterly or upon request.(Resident #1) These failures could place all residents who had a facility trust fund account at risk of financial misappropriation.

Inspectors wroteBased on interview and record review the facility failed to ensure conveyance of resident funds within 30 days of discharge for 1 of 1 resident (Resident #3) reviewed. The facility failed to ensure Resident #3's funds were conveyed after death within 30 days. This failure could affect residents by not giving them access to funds in a timely manner.

Inspectors wroteBased on interviews and record reviews, the facility failed to consult with the resident's physician when there is a significant change in the resident's physical, mental, or psychosocial status: that is, a deterioration in mental health, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 residents (Resident #2) for a change of condition. The DON failed to immediately consult with Resident #2's physician when she was found in her bed unresponsive but was still breathing on 1/22/26 at approximately 4:30 a.m. At approximately 11:10 a.m., Resident #2 had seizure like activity and was sent to the hospital. Resident #2 was diagnosed with a non-traumatic brain hemorrhage and subsequently died. An IJ was identified on 2/5/26. The IJ template was provided to the facility on 2/5/26 at 4:00 p.m. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 1 of 5 residents (Resident #2) who were reviewed for quality of care. The facility failed to provide the care and services to Resident #2 when her physician was not contacted on 1/22/26 at approximately 4:30 a.m. when she was found in her bed unresponsive but still breathing. Because the physician was not contacted or included in Resident #2's change of condition, she did not receive the best care available. An IJ was identified on 2/5/26 at 4:00 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: A. Ensure facility staff wore hair restraints and beard guards while in the kitchen. B. Ensure stored and cooked food was properly labeled, dated and covered. C. Ensure hand hygiene and use of proper serving utensils was maintained during serving a mealD. Ensure menu substitutions were documented. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.

Inspectors wroteBased on observation the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles to include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 (Hall 100 and Hall 200) of 2 medication carts. -1 bottle of Probiotic had an expiration date of 11/2025.-1 bottle of Tylenol had an expiration date of 10/2019.-Resident #1's Novolog did not have an open date on the medication.-Resident #36's Novolog and Lantus did not have open dates on the medications.-Resident #37 had 2 Wexela inhalers that did not have open dates written on the medications-Resident #37's 2-Wexela inhalers had expiration dates of 07/2023 and 10/2023.-2 loose pills were in the bottom of Medication cart for Hall 200. [...]

Inspectors wroteBased on observation, interview, and record review; it was determined the facility failed to ensure each resident was provided with the right to have personal privacy during medical treatments, for 1 (Resident #8) of 13 residents reviewed for privacy. -RN G and CNA I did not close the window blinds to provide privacy for Resident #8 during wound care. This failure could place residents at risk of feeling shame or embarrassment, lowered self-esteem, and a lack of a dignified existence. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #2) of 13 residents reviewed for accuracy of assessment. The facility coded Resident #2 as receiving insulin when she did not receive insulin. This failure could place residents at risk of receiving unnecessary care/medication. Findings Included:Record review of Resident #2's admission record dated 01/13/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and unspecified atrial fibrillation (irregular heart rhythm). [...]

Inspectors wroteBased on interviews and record reviews 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 of a resident's admission for 1 (Resident #28) of 13 residents reviewed for care planning. The facility failed to develop a baseline care plan for Resident #28 within 48 hours of his admission on [DATE]. This failure could place newly admitted residents at risk of not receiving effective, person-centered care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #2 and Resident #28) of 13 residents reviewed for comprehensive care plans.1. The facility failed to include Resident #2's antidepressant medication in her care plan.2. The facility failed to include Resident #28's rash in his care plan. These failures could lead to residents not receiving needed care and or symptom monitoring. Findings Included:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed by 6 of 6 residents who received pureed meals. A. The facility did not serve onions and peppers to residents with a pureed meal for the lunch meal on 1/13/26 as directed by the menu. These failures could place all residents who received food from the kitchen at risk of decreased meal satisfaction, potential weight loss due to poor meal intake, not having their nutritional needs met, and a decline in health status.

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 to help prevent the development and transmission of communication diseases and infections for 2 (Resident #1 and Resident #37) of 13 residents reviewed for infection control. -LVN F failed to use proper hand hygiene techniques when preparing and administering medications to Resident #1.-LVN F failed to clean glucometer before and after performing glucose check for Resident #1.-Facility failed to have proper EBP signage on Resident #37 who had a foley catheter. These failures had the potential to affect residents by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the governing body of the facility appointed an administrator, who was licensed by the state, to be responsible for the management of the facility and reported to the governing body for 1 of 1 facility reviewed for governing body. The facility had not had an administrator since 09/02/2025. This could place residents at risk of decreased quality of life and quality of care due to lack of staff oversight and monitoring of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services that assure the accurate dispensing and administering of all drugs for two (Resident #1, #2) of five residents reviewed for pharmacy services. Resident #1 who was nonverbal and bedridden and dependent on staff for all care needs, tested positive for barbiturates on 11/14/2025. The medical record did not contain documentation of a current barbiturate prescription. Resident #2's was prescribed Primidone 50mg, a medication that metabolizes in the body as a barbiturate was missed per the MAR on 11/08/2025 and 11/09/2025. These failures could place residents in the facility at risk of adverse drug reactions, untreated or uncontrolled medical conditions and a decline in health status. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure all food in the dry pantry and cold storage were properly sealed, labeled and dated. The facility failed to ensure all foods in the dry pantry were at least 18 inches off the floor as required by facility policy for dry pantry storage. These failures could place residents at risk of residents at risk of food-borne illness and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property are reported immediately, but no 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 administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 16 residents (Residents #5 and #27) reviewed for abuse and neglect. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 2 of 16 (Residents #5 & #27) residents reviewed for abuse and neglect. The facility failed to conduct a thorough investigation when Resident #5 fell from his wheelchair unobserved and obtained a skin tear to the bridge of nose and abrasion to left side of forehead. The facility failed to conduct a thorough investigation when Resident #27 fall leading to a head wound on her left side. This failure could place residents at risk of abuse and neglect.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff and individuals providing services under a contractual agreement, consistent with their expected roles for 4 of 11 (interim DON, LVN B, CNA C and CNA D) staff reviewed for nursing home training. The facility failed to ensure Interim DON, LVN B, CNA C and CNA D were trained in the prevention of Resident Abuse, Neglect and Exploitation, HIV Policy and Procedures, Fall Prevention, Use of Restraints, Emergency Procedures and Dementia. This failure could place residents at risk for a diminished quality of life and diminished psychosocial well-being, due to lack of training in essential resident care and facility practice.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment for 1 of 16 (Resident #5) reviewed for care plans. This facility failed to implement the comprehensive care plan for Resident #5, resulting in a fall with injury. This failure could place residents at risk of not receiving the care needed to live at their highest practicable level of health and mental well-being.

Inspectors wroteBased on interviews, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 (10/12/2024) of the 90 days reviewed. The facility did not have an RN working in the facility on 10/12/2024. This failure has the potential to affect the residents in the facility and place them at risk of not having staff with advance care skills available to assist in their care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen observed for kitchen sanitation. The facility failed to: A. Ensure general cleanliness was maintained. B. Ensure food items were properly stored. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, which included but not limited to the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 16 residents (Resident #3) reviewed for self-determination. The facility failed to ensure Resident #3 was allowed to choose the type of foods he preferred when he expressed he would like all the foods the other residents were served. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that were important in their life and a decrease in their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed, for 2 out of 3 residents that received pureed food (Resident #3 & Resident # 29), in that: 1. The facility failed to ensure Resident # 3 received pureed bread on 10/16/23. 2. The facility failed to ensure Resident # 29 received pureed bread on 10/16/23. These failures could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances.