Park View Rehabilitation Center

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that only licensed staff administered medications. Additionally, the facility failed to ensure that narcotics were counted only by qualified personnel authorized to manage controlled substances, and that licensed nursing staff completed the shift-to-shift narcotic count together. These failures allowed an unlicensed staff member (CNA) to attempt medication administration and perform narcotic counts, both beyond their scope of practice. The facility reported a census of 42 residents.

Inspectors wroteBased on staff interviews, the facility failed to ensure that medication cart keys were secured and handled exclusively by qualified personnel, allowing a Certified Nursing Assistant (CNA), who is unauthorized to manage controlled substances, to possess the keys and conduct narcotic counts. The facility reported a census of 42 residents. Findings Include: During an interview on 6/10/26 at 10:23 AM, Staff B, CNA, admitted she performed narcotic counts with Staff C, Licensed Practical Nurse (LPN), and Staff D, LPN, separately, rather than together as directed by the Assistant Director of Nursing (ADON). Although Staff B stated she lacked the licensure to conduct counts, she claimed Staff C, LPN, insisted she participate and sign the documentation. Staff B noted she performed counts with each nurse individually, remarking that the CNAs were caught in the middle. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that the resident's physician and responsible party were notified regarding the failure to administer prescribed, scheduled medications including a high-risk medications for 2 of 3 residents reviewed (Resident #1 and #2). The facility reported a census of 42 residents.

Inspectors wroteBased on staff and resident interviews and record review, the facility failed to ensure residents remained free from significant medication errors. On 4/21/26, staff failed to administer scheduled evening medications for 2 of 3 resident reviewed (Resident #1 and #2). Instead, the medications were found in envelopes stapled to the residents' respective medication bubble packs. The facility reported a census of 42 residents.

Inspectors wroteBased on the record review and interviews with facility staff, the facility failed to maintain accurate documentation of medication administration as not administered on 4/21/26 for 2 of 3 residents reviewed (Residents #1 and #2). The facility reported a census of 42 residents.

Inspectors wroteBased on resident council meetings, Electronic Health Record (EHR)review, document review, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 6 residents reviewed (Resident #27, #53, #11 and #15). The facility reported a census of 45 residents.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal service to prevent cross contamination, not dating open food items and not disposing of expired food items. The facility reported a census of 45 residents.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to have the necessary required members attend quarterly quality assurance meetings. The facility reported a census of 45 residents.

Inspectors wroteBased on Electronic Health Records (EHR) review, Medication Administration Records - Treatment Administration Records (MAR-TAR), resident interviews, staff interviews, and policy review the facility failed to provide an opportunity for bath or shower and failed to apply edema wear as ordered by the physician to 3 of 3 residents reviewed (Resident #4, #27 and #11). The facility reported a census of 45 residents.

Inspectors wroteBased on Electronic Health Record (EHR) review, resident interview, staff interview, and policy review the facility failed to provide range of motion (ROM) services to a resident with limited ROM to prevent further decrease in range of motion or development of contractures for 2 of 3 residents reviewed (Resident #4 and #9). The facility reported a census of 45.

Inspectors wroteBased on observation, clinical record review, and staff interview, the facility failed to implement appropriate infection prevention and control practices to prevent the spread of infection. Specifically, the facility failed to clean equipment between resident use for 1 of 5 residents reviewed (Resident #15). The facility also failed to follow Transmission-Based Precautions (TBP) when delivering a meal tray to a resident with COVID-19 for 1 of 2 residents reviewed (Resident #37). Additionally, the facility failed to follow current Centers for Disease Control and Prevention (CDC) guidelines by not implementing Enhanced Barrier Precautions (EBP) during a wound care dressing change to prevent the spread of multidrug-resistant organisms (MDROs) for 1 of 3 residents reviewed (Resident #11). The facility reported a census of 45 residents. Findings Include: 1. [...]

Inspectors wroteBased on record review, staff and family interview, the facility failed to allow a resident representative/Power of Attorney (POA) assist a cognitively impaired resident with decision making for 1 resident reviewed (Resident #4). The facility reported a census of 47 residents.

Inspectors wroteBased on record review and staff interview, the facility failed ensure an As Needed (PRN) psychotropic medication was only continued after 14 days with a provider written rationale and end date for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 47 residents.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure interventions were in place to prevent falls, and failed to ensure the completion of neuro assessments after falls for 1 of 3 resident's reviewed (Resident #4). The facility reported a census of 47 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 resident's reviewed (Resident #1). The facility reported a census of 43 residents. Resident #1 had wounds that were deteriorating. The resident was seen in the wound center. The facility sent the assessment of the wound in a fax to the PCP on 8/21/25 and wrote the resident would be seen in the wound center 8/22/25. The PCP replied okay. The PCP was not the wound center provider. The resident did not have an appointment on 8/22/25. The facility did not follow up until 8/27/25 with an assessment. The fax notified the wound center physician that the wound deteriorated and had a foul odor. The physician ordered a different treatment until seen on 8/29/25. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident #2). Resident #1 fell on 7/10/25 fracturing his right elbow that would require surgical repair, and a laceration near his right eye requiring 7 sutures. The resident had a pressure alarm that did not sound to alert staff the resident was getting up without assistance. Staff failed to determine why the alarm did not sound. On 7/11/25 the resident fell again fracturing his left elbow, also requiring surgical repair. The resident's pressure alarm again failed to sound to alert staff the resident was getting up. The facility reported a census of 43 residents.

Inspectors wroteBased record review and staff interview, the facility failed to notify the resident's representative of a change in condition for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 43 residents.

Inspectors wroteBased on observation, resident and staff interviews, clinical record review, and policy review, the facility failed to develop and implement a Comprehensive Care Plan for 4 of 12 residents reviewed (Resident #4, #15, #16, #22). The Care Plans failed to identify target behaviors related to the use of psychotropic, antianxiety, and antidepressant medications, and non-pharmalogical interventions. The facility reported a census of 38 residents.

Inspectors wroteBased on observations, staff interviews, clinical record reviews, and policy reviews the facility failed to review and revise the Care Plan interventions for 2 of 12 residents reviewed (#4, #17). The facility failed to revise Care Plan interventions for a resident who had a change in oxygen use and changed from weight gain to weight loss, and a resident who had a new intervention for fall prevention.

Inspectors wroteBased on observations, record review, staff interviews, the facility failed to have an emergency tracheostomy kit with obturator at bedside for 1 of 1 residents reviewed (Resident #24). The facility reported a census of 38.

Inspectors wroteBased on observations, staff interview, and infection control policy review, the facility failed to complete hand hygiene when assisting residents to eat, at the same time, in an effort to reduce the risk of spreading infection for 3 out of 3 residents during meal service (Residents #6, #28, # 32). The facility reported a census of 39 residents.

Inspectors wroteBased on staff interviews, resident interviews, facility documentation, and review of facility policy, the facility failed to provide care for 2 of 6 residents reviewed (Resident #5 and #6) in a manner to promote dignity and respect. Interviews determined that Resident #5 sat visibly incontinent of urine in a common area for visitors and other residents to witness his incontinence for over 2 hours. In addition, Resident #6 felt that the staff ignored her husband when they turned off his call light and she did not hear the staff member state she would be back.

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to provide adequate transfers for 2 or 6 residents reviewed (Resident #2 and #1) to ensure a safe transfer according to plan of care. The facility did not provide the number of staff needed for each transfer according to the care plan. The facility reported a census of 37 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review the facility failed to provide adequate incontinence care in a timely manner for 1 of 5 resident reviewed (Resident #5).