Park Vista at Morningside

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infection. * The facility failed to maintain an accurate infection control surveillance log and match the data in the QA infection control for June, July, September, and October 2025. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. * The facility failed to ensure the EBPs were followed for Resident 55 when the RNA 1 did not wear the appropriate personal protective equipment (PPE) before providing care to the resident. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure injury (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of the existing pressure ulcer for one of two final sampled residents (Resident 55) reviewed for pressure injury. * The facility failed to ensure Resident 55's pressure injury was evaluated regularly. * The DSD/IP failed to ensure to follow the physician's order to cleanse Resident 55's pressure injury with normal saline during wound care observation. These failures posed the risks of complications and delayed wound healing for Resident 55.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for one final sampled resident (Resident 65) reviewed for the use of an indwelling urinary catheter. * The facility failed to monitor Resident 65's fluid output every shift for the use of the indwelling urinary catheter. In addition, the facility failed to provide bladder training prior to discontinuing the indwelling urinary catheter as ordered by the physician. These failures had the potential for not providing the necessary care and services and posed a risk for adverse complications related to the indwelling urinary catheter use for Resident 65.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of the GT was provided for one of two final sampled residents (Resident 42) reviewed for the GT use. * The facility failed to ensure Resident 42's HOB (head of bed) was elevated at a 90-degree angle during the infusion of the enteral feeding via GT as per the physician's order, to reduce the risk of aspiration (inhaling foreign material i.e. food, liquid or vomit, into the lungs). This failure posed the risk of complications related to the use of the GT for Resident 42.

Inspectors wroteBased on observation, interview, medical record review and facility P&P, the facility failed to ensure the appropriate physicians' orders were obtained for one of two final sampled residents (Resident 35) reviewed for the intravenous therapy. * Resident 35 did not have current physicians' orders for the midline catheter's monitoring and dressing changes. This failure had the potential for the residents not receiving proper midline catheter care, as well as a delay in identifying and preventing potential catheter complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the respiratory care and services for two of two final sampled residents (Residents 36 and 66) reviewed for respiratory care. * The facility failed to follow the physician's order for the administration of continuous oxygen and failed to ensure the nasal cannula was labeled with date for Resident 36. * The facility failed to clean Resident 66's CPAP (Continuous Positive Airway Pressure, is a machine that uses mild air pressure to keep breathing airways open while a person sleeps) machine as ordered by the physician. These failures had the potential for the residents not to receive the appropriate care and may negatively impact on the residents' medical conditions.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper medication storage. * The facility failed to ensure medications were not kept in the resident's room for one of 15 final sampled residents (Resident 42). The facility failed to ensure a container of CBD Pain Relief Ointment (pain reliever) medication was not kept at Resident 42's bedside table. * The facility failed to ensure the medications were stored and labeled properly in one of two medication carts inspected (Medication Cart A). * The facility failed to ensure the orally administered medications were stored separately from the externally used medications in one of two medication storage rooms inspected (Medication Room A). [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill sets to safely perform the daily operation of the Food and Nutrition Services Department. * The Dietary Aide failed to check the temperature of the hot beverages correctly during tray line. This failure posed the risk of burn injury to the residents receiving hot beverages from the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the Dietary Aide sanitized the thermometer before checking the temperature of hot beverage during tray line. * The facility failed to ensure one of the three ice machines (Ice Machine 1) was sanitary, kept free of buildup, and free from accumulation of rust. These failures had the potential to cause foodborne illnesses for the residents receiving beverages and ice from the kitchen.

Inspectors wroteBased on interview and facility document review, facility failed to have a full-time, dedicated IP. This failure had the potential for the Infection Prevention and Control Program not being implemented without the proper oversight.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure care was provided in a manner which promoted dignity and respect for one of one final sampled resident (Resident 65) reviewed for the use of an indwelling urinary catheter (flexible tube used to empty the bladder and collect urine in a drainage bag). * The facility failed to ensure Resident 65's indwelling urinary catheter collection bag was inside the privacy bag. This failure had the potential to negatively impact Resident 65's emotional well-being.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to protect the residents' identifiable information.* The facility's survey results binder for public viewing included four confidential resident rosters. This failure resulted in confidential resident information being accessible to the public.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the MDS assessment was coded accurately for one of three residents reviewed for closed records (Resident 6). * Resident 6's MDS assessment was not coded accurately to show he received hospice services. This failure posed the risk for the resident not to have an individualized plan of care based on the resident's specific needs, and incorrect data being transmitted to CMS.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for two of 15 final sampled residents (Residents 35 and 41). * The facility failed to develop a care plan to address Resident 41's use of the midodrine (blood pressure medication) medication. * The facility failed to develop a care plan to address Resident 35's midline catheter (long, thin, flexible tube inserted into a peripheral vein and advanced until the tip rests below the armpit) use. These failures had the potential risk of not providing the appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 4) reviewed for safety was free from accident/hazards. * The facility failed to ensure Residents 4 was evaluated to handle and consume hot beverages as per the facility's P&P. In addition, Residents 8 and 9 were also not evaluated to handle and consume hot beverages. * RNAs 1 and 2 failed to notify a licensed nurse immediately after Resident 4 spilled hot tea onto her lap. * The facility failed to ensure Resident 4 was provided the immediate and appropriate interventions when Resident 4 spilled hot tea to her left upper thigh. In addition, the facility failed to obtain a physician's order to properly treat a burn for Resident 4's left thigh. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary wound care services to one of nine sampled residents (Resident 1). * The facility failed to provided Resident 1's wound treatment as per the physician's order. In addition, the facility failed to accurately monitor and document the wound care provided to Resident 1. This failure had the potential for the resident's wound to become worse and negatively affect the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care services were provided for one of nine sampled residents (Resident 2). * The facility failed to ensure Resident 2 was provided with the continuous oxygen via nasal cannula and Resident 2's oxygen saturation was maintained greater than 92% as ordered by the physician. These failures had the potential for the resident to not receive the necessary respiratory services and negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections for three of nine sampled residents (Residents 4, 6, and 7). * Treatment Nurse 1 failed to perform hand hygiene and changed her gloves after removing the soiled wound dressing for Resident 4. In addition, Treatment Nurse 1 failed to dispose the unused gauze brought in resident's room and ensure the alcohol based sanitizer used was not expired. * CNA 4 failed to wear gloves and perform hand hygiene after touching contaminated items inside Resident 4's contact isolation room. In addition, CNA 4 then proceeded to deliver Resident 7's meal tray without performing hand hygiene. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical information was complete and accurate for two of nine sampled residents (Residents 1 and 4). * The facility failed to ensure Resident 1's intake, output, and eating percentage documentation were complete and accurate. * The facility failed to document the incident when Resident 4 spilled hot tea on her left thigh on 9/3/24. These failures had the potential for the residents to receive inadequate care as their clinical information were incomplete and inaccurate.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure proper labeling and dating of foods in the kitchen. * The facility failed to ensure proper labeling and dating of foods in the refrigerator used for residents' food brought in by visitors and expired foods were discarded. * The facility failed to ensure the foods were stored off the floor. * The facility failed to ensure the plate lowerator (adjustable heated plate dispenser), can opener, kitchen microwave, oven, and warmer were clean. * The facility failed to ensure the egg salad was not stored on the shelf containing raw meats. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the RD evaluations and interventions related to weight loss were conducted timely for one of one final sampled residents (Resident 18) reviewed for nutrition. This failure had the potential for further weight loss and not meeting the nutrition needs for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure four of four final sampled residents (Residents 31, 32, 36, and 18) reviewed for respiratory care were provided with the appropriate respiratory care. * The facility failed to ensure Resident 36's oxygen was administered as ordered. In addition, the facility failed to change the humidifier and the oxygen nasal cannula (flexible tube to deliver oxygen into the nose) timely. * The facility failed to ensure Resident 32's oxygen nasal cannula was stored in a sanitary manner when not in use. * The facility failed to ensure Resident 31's oxygen nasal cannula was stored in a sanitary manner and changed timely. * The facility failed to ensure Resident 18's oxygen nasal cannula was stored in a sanitary manner. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services necessary to ensure the accurate reconciliation and disposal of medications. * The facility failed to ensure one of 17 final sampled residents (Resident 25) medications were not left at the resident's bedside. In addition, the facility failed to ensure the pharmaceutical services were provided to meet the needs of one nonsampled resident (Resident 2). * The facility failed to ensure the count performed for all controlled medications in the Omnicell (automatic drug delivery system) was accurate as per the facility's P&P. This failure posed the risk of medication diversion. * The facility failed to ensure Resident 2's routine medication was available. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 17 final sampled residents (Resident 25) was free of significant medication errors. * The facility failed to ensure Resident 25 was administered the piperacillin sodium tazobactam medication (antibiotic) as ordered by the physician. This failure had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed ensure proper storage and label of medications in one of two medication storage rooms (Medication room [ROOM NUMBER]) and two of three medication carts (Medication Carts A and C) when: * An opened tuberculin (medication used to help diagnose tuberculosis) vial was stored in the refrigerator inside Medication room [ROOM NUMBER] without an open date. An opened box of instant food thickener was stored in Medication room [ROOM NUMBER] and contained multiple expired packets of food thickener. In addition, a bag of the home medications without a resident's name was stored in Medication room [ROOM NUMBER]. * Temperature log for Medication room [ROOM NUMBER] had multiple missing entries on multiple dates. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the menu was followed for three of 50 residents who received food from the kitchen. * Residents 22, 40, and 43 were not provided with the garlic breadstick as per the lunch menu on 12/2/24. This failure had the potential for the residents not receiving adequate nutrition and not receiving the menu as planned.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 17 final sampled residents (Resident 30) had accurate and complete medical record. * The facility also failed to ensure the monitoring of behavior for the psychotropic medication on Resident 2's MAR was completed. This failure had the potential for the resident's care needs not being met as the medical record was incomplete and inaccurate.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the safe and sanitary environment to help prevent the development and transmission of infections to two of 17 final sample residents (Residents 26 and 31) and one nonsampled resident (Resident 2) when: * The facility failed to ensure LVN 3 donned the appropriate PPE when administering medications through the GT tube for Resident 26 who was on the EBP precautions. In addition, Resident 26's isolation cart was touching the trash inside the resident's room. *The facility failed to ensure LVN 2 donned the appropriate PPE when administering medications to one nonsampled resident (Resident 2) on the EBP precautions. * A stack of incontinence briefs was observed on top of the isolation cart inside the Room A. In addition, the isolation cart was observed touching the trash bin. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure four of five final sampled residents (Residents 12, 21, 25, and 507) and one nonsampled resident (Resident 24) reviewed for immunizations were educated and offered the influenza and pneumococcal vaccinations as evidenced by: * The facility failed to offer the educational materials for the risks and benefits for the pneumococcal and influenza vaccines to Residents 12, 21, 24, 25, and 507 as per the facility's P&P. In addition, the facility failed to indicate which pneomococcal vaccine was offered for Residents 12, 21, 24, 25, and 507. These failures put the residents at risk for infection and transmission of pneumococcal and influenza infections.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential kitchen equipment was maintained in safe operation condition when the ice machine manufacturer cleaning and sanitizing instructions were not followed for two of three ice machines (Ice Machines 1 and 2) in the facility. This failure had the potential to result in the equipment to not function in the way it was intended which could affect the health status of the residents.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete; and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for three of three final sampled residents (Residents 507, 30, and 38) reviewed for the entrapment risk. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 17 final sampled residents (Resident 507) was assessed to determine if it was safe to self-administer their medications. In addition, the facility failed to ensure Resident 507 had the physician's order and care plan developed prior to self-administering their medications. These failures had the potential for the unsafe medication administration and negatively impact the resident's physiological well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the call light was within reach for one nonsampled resident (Resident 307). This failure had the potential for Resident 307 not being able to summon help if needed and not receiving the care timely.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide and document in the medical record the information on how to formulate an advance directive for one of two final residents (Resident 508) reviewed for an advance directives. * Resident 508's responsible party had not been provided the information regarding their rights to formulate an advance directive. This failure had the potential for the facility to provide treatment and services against the resident's wishes.

Inspectors wroteBased on interview and facility document review, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 for one of three residents (nonsample resident, Resident 44) reviewed for beneficiary notices. This failure had the potential to not allow Resident 44's responsible party to make an informed decision regarding their Medicare services.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the MDS for discharge was completed and transmitted to CMS for two nonsampled residents (Residents 42 and 46) reviewed for resident assessments. This failure had the potential to affect the provision of care or services for the residents.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in three of five garbage dumpsters. This failure had the potential to attract pests/rodents that carried diseases.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement the P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Resident's 1 allegation of physical abuse was not reported to the local enforcement agency as per the facility's P&P. This failure had the potential for the abuse allegation going unreported and uninvestigated.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure proper labeling and dating of foods in the kitchen * The facility failed to ensure proper labeling and dating of foods in the refrigerator used for residents' food brought in by visitors. In addition, the facility failed to ensure the foods stored in the refrigerator belonged to the residents and not the staff, and expired foods were discarded. * The facility failed to ensure the foods were stored off the floor. * The facility failed to ensure a proper sanitary condition of the ice machine. * The facility failed to ensure the plate lowerator (adjustable heated plate dispenser) and resident refrigerator were clean. * The facility failed to ensure the cutting boards were in sanitary condition. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 16 final sampled residents (Residents 38 and 39) and one nonsampled resident (Resident 23) were provided with the respiratory care to prevent possible respiratory tract complications. * The facility failed to ensure Resident 38 received the necessary care for breathing treatments via CPAP machine. * The facility failed to provide the oxygen therapy as ordered by the physician to Resident 39. * The facility failed to ensure Resident 23's nebulizer mask was dated and stored in a sanitary manner. These posed the risk of the residents not receiving the appropriate breathing treatments and the spread of infection to the residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 16 final sampled residents (Resident 31) remained free from accident hazards related to the use of elevated side rails. * The facility failed to ensure the physician's order was obtained and the care plan problem was developed prior to the use of side rails for Resident 31. This had the potential to put the resident at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 16 final sampled residents (Resident 41). * Resident 41's lorazepam (antianxiety medication) Controlled or Antibiotic Drug Record did not match Resident 41's MAR. LVN 1 did not document the lorazepam administration in the resident's MAR. This failure posed the risk for diversion of controlled medications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * The facility failed to discard outdated sterile dressing kit tray found in the intravenous cart (Medication Cart B). This posed the risk for this cleaning wound supplies lose their sterility making them unsafe to use. * The facility failed to ensure the oral medications were stored separately from externally used medications and failed to ensure the Sani wipes were stored separately from the medications found in Medication Cart A. This posed the risk for cross-contamination of the medications. * The facility failed to label three bottles of medications for one nonsampled resident (Resident 20) and failed to dispose of the discontinued medication for one nonsampled resident who had been discharged (Resident 459) from the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their Quality Assessment and Assurance (QA&A) plan of action. There was no documentation to show the facility was monitoring the effects of the corrective action plan to identify if they had achieved and sustained the improvement for the repeated deficient practice cited at F695 in accordance with their POC for an abbreviated survey completed on 2/18/20. This had the potential to affect the quality of care for all the residents in the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the essential equipment was maintained in the safe operating condition. * The facility failed to ensure two glucometers (a device which measures the amount of sugar in the blood) currently used by two nonsampled residents (Residents 158 and 458) stored in the medication carts were properly calibrated. In addiition, the facility failed to ensure the glucometer monitoring log were completed. These posed the risk for inaccurate blood glucose test results and inappropriate treatments. * The facility failed to ensure there was no ice build up in the chest freezer in the kitchen. In addition, the facility failed to ensure the microwave in the kitchen was free from corrosion, chipped paint, and rust. [...]