Park Vista Nursing and Rehab

Inspectors wroteBased on observation, record review, review of hospital records, review of a facility investigation, review of an emergency medical service (EMS) run report, review of the time and date weather historical data, facility policy review, and interview, the facility failed to ensure adequate supervision and monitoring to prevent hospitalization for hypothermia for Resident #66. In addition, the facility failed to ensure fall interventions were in place for Resident #48. This affected two residents (#66 and #48) of three reviewed for accidents. The facility census was 94. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to serve palatable meals, and ensure meals were served in a manner that prevented possible contamination. This affected eight residents (Residents #22, #25, #28, #57, #63, #72, #73, #80 and #84) of eight reviewed for food quality, palatability and service, and had the potential to affect all 94 residents in the facility with the exception of Residents #19, #87 and #91, who did not receive meals by mouth.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure residents were offered showers on a consistent basis. This affected two residents (Residents #48 and #59) of five residents reviewed for activities of daily living (ADL) assistance. The facility identified 75 Residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, 19, #20, #21 #22, #23, #24, #25, #26, #27, #28, #29, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55 #56, #57, #58, #59, #60, #61, #62, #63, #65, #67, #68, #69, #70, #71, #72, #73, #74 #92, #94, #95, #96 and #97) as needing assistance with showers. The facility census was 94.

Inspectors wroteBased on record review, observation and interview, the facility failed to implement timely treatment for skin breakdown for Resident #59 and failed to ensure treatments were completed as ordered for Resident #90. This affected two residents (#59 and #90) of three residents reviewed for skin care. The facility census was 97.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to maintain infection control procedures during wound care for Resident #61. This affected one resident (#61) of three residents reviewed for wound care. The facility census was 97.

Inspectors wroteBased on observation, invoice review and interview, the facility failed to ensure the dishwasher was in good working condition. The facility has served all meals since 05/09/25 on paper products with plastic silverware when the dishwasher broke. This affected 90 of 92 residents residing in the facility. Residents #8 and #88 did not receive food from the kitchen. The facility census was 92.

Inspectors wroteBased on observation, interview, record review, review of the AccuWeather forecast and facility policy review, the facility failed to maintain a comfortable temperature in the facility. This affected six (Residents #3, #15, #18, #55, #64, and #84) and had the potential to affect all residents in the facility. The facility census was 92.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to provide a safe, functional, sanitary and comfortable environment for all residents. This had the potential to affect all 89 residents residing in the facility.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to store food in a manner to prevent contamination. The facility also failed to have test strips at the three-sink manual dishwash area to test for proper sanitation levels and failed to maintain clean floors in the kitchen. In addition, the facility failed to ensure refrigerator maintenance on Nursing Unit One. This had the potential to affect 99 residents receiving food from the kitchen. The facility identified two residents (#19 and #66) who received nothing by mouth. The facility census was 101.

Inspectors wroteBased on observation, interview, laundry work order review and facility policy review, the facility failed to maintain the walk-in refrigerator, walk-in freezer and automatic dishwasher in a safe operating condition. This had the potential to affect 99 residents receiving dietary services. There were two residents (#19 and #66) identified by the facility as receiving nothing by mouth. In addition, the facility failed to ensure the laundry room, washers and dryers were maintained in clean working order. This had the potential to affect all residents residing in the facility. The facility census was 101.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure sufficient staffing to meet the needs of Resident's #34, #46, #98, and #203. This affected four residents (#34, #46, #98, and #203) and had the potential to affect 41 additional residents (#2, #7, #9, #10, #12, #14, #18, #22, #28, #30, #38, #40, #41, #42, #43, #49, #53, #55, #56, #57, #61, #64, #65, #66, #68, #70, #72, #73, #75, #76, #77, #82, #83, #88, #90, #96, #102, #103, #204, #205, and #206), residing on the nursing two and rehab two nursing units. The facility census was 101.

Inspectors wroteBased on observation, record review, interview, review of the manufacturer recommendations for a glucometer and facility policy review, the facility failed to ensure Residents #1 and #95, with physician ordered isolation precautions, had the appropriate signage on the entrance door to the resident's rooms indicating the type of precautions and type of personal protective equipment (PPE) required when providing care. This finding affected two residents (#1 and #96) of four residents reviewed for isolation precautions and had the potential to affect an additional 35 residents (#5, #11, #12, #16, #24, #26, #30, #33, #34, #38, #40, #43, #47, #53, #55, #57, #58, #61, #63, #64, #65, #82, #83, #84, #89, #90, #94, #98, #99, #102, #203, #205, #206, #253, #256) residing on the 200 and 300 Rehab Units. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident's #46 and #98 were transported to their scheduled appointments. This affected two residents (#46 and #98) out of three residents reviewed for transportation to appointments. The facility census was 101.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure Residents #57 and #90 and had a clean, sanitary and homelike environment. This affected two residents (#57 and #90) out of three residents reviewed for sanitary homelike environment. The facility census was 101.

Inspectors wroteBased on record review, interview and facility policy review, the facility did not ensure a baseline care plan was completed within 48 hours for Residents #11, #92, and #257. This affected three residents (#11, #92, and #257) of the 30 resident records reviewed. The facility census was 101.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure an initial care conference was completed for Resident #11 and failed to ensure the quarterly care conference was completed for Resident #31. This affected two residents (#11 and #31) of the 30 resident records reviewed. The facility census was 101.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure Resident #29 was provided adequate nail care. This finding affected one resident (#29) of four residents reviewed for activities of daily living (ADL). The facility census was 101.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure Resident #49 was provided an ongoing activities program to meet the needs of the resident. This finding affected one resident (#49) of one resident reviewed for activities. The facility census was 101.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure orthotics/braces were applied as ordered for Resident #86. This affected one resident (#86) of five residents reviewed for limited range of motion (ROM) and had the potential to affect 13 residents (#5, #6, #7, #29, #31, #40, #42, #43, #64, 72, #81 and #86) identified by the facility as requiring application of orthotics/braces. The facility census was 101.

Inspectors wroteBased on record review, review of the facility incident log, interview and review of the facility post fall investigation, the facility failed to ensure Resident #47 had a comprehensive fall assessment completed after experiencing falls. This affected one resident (#47) out of three residents reviewed for falls. The facility census was 101.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure Residents #34 and #203's incontinence care was provided timely and failed to ensure Resident #203's care planned interventions for reporting changes in skin status were implemented. This affected two residents (#34 and #203) out of three residents reviewed for incontinence care. The facility census was 101.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure Resident #13 was provided with the diet as ordered and failed to ensure Resident #86 was weighed weekly as ordered. This affected two residents (#13 and #86) of five residents reviewed for nutrition. The facility census was 101.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure Resident #66's tube feeding was infusing as ordered by the physician. This affected one resident (#66) of one resident reviewed for tube feedings. The facility census was 101.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #206's pain was addressed timely. This affected one resident (#206) out of three residents reviewed for pain. The facility census was 101.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure Resident #4's thrill and bruit were assessed every shift per facility policy. This finding affected one resident (#4) of one resident reviewed for dialysis services. The facility census was 101.

Inspectors wroteBased on record reviews, interviews and facility policy review, the facility failed to ensure Resident #31 was free from unnecessary medications and failed to ensure pharmacy recommendations were conducted monthly for Resident #14. This affected two residents (#31 and #14) of six residents reviewed for unnecessary medications. The census was 101.

Inspectors wroteBased on record review, interviews and facility policy review, the facility failed ensure Resident #86's medical record accurately reflected the status of a right lower extremity brace. This affected one resident (#86) of 33 residents who had a review of medical records. The facility census was 101.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a base line care plan was completed for one resident (#99) out of three reviewed for care plans. The facility census was 96.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the kitchen was clean and sanitary and items were properly stored and dated. This had the potential to affect all 82 residents residing in the facility. The facility identified all residents as receiving meals from the kitchen.

Inspectors wroteBased on record review and interview the facility failed to ensure physician's orders were followed for Residents #69 and #83. This affected two residents (#69 and #83) of three residents reviewed for following physician's orders. The facility census was 82.

Inspectors wroteBased on observation, record review, interview and facility policy review the facility failed to ensure Resident #87, who required staff assistance for activities of daily living (ADL) care, received adequate and timely incontinence care. Actual Harm occurred on 04/10/24 when Resident #87, who was totally dependent on staff for bed mobility and toileting went from 04/10/24 at approximately 6:00 A.M. to 11:52 A.M. (almost six hours) before being provided incontinence care. Resident #87 was observed to be saturated in urine resulting in a red, bleeding, open area to her right thigh that was approximately the size of a dime. Resident #87 revealed her skin was raw, hurt, and burned from the lack of timely incontinence care. She also was observed to have her incontinence brief fastened rather than being left open as ordered by the physician. [...]

Inspectors wroteBased on interview, record review, review of a self-reported incident (SRI), and review of the facility policy revealed the facility did not timely report an allegation of misappropriation to the state agency. This affected one resident (#88) out of one resident reviewed for misappropriation. The facility census was 87.

Inspectors wroteBased on record review and interviews, the facility did not ensure a thorough post-fall investigation was completed to identify hazards, and evaluate and analyze hazards and risks to prevent falls for Resident #89. This affected one resident (#89) of four residents reviewed for accidents/hazards. The facility census was 88.

Inspectors wroteBased on observation, interview, medical record review, and policy review the facility failed to ensure Resident #32 was treated in a dignified manner that included providing privacy during incontinence care. This affected one resident (#32) of three residents reviewed for incontinence care. The facility census was 86.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide nail care to Resident #55. This affected one resident (#55) of three residents reviewed for activities of daily living. The facility census was 86.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections to maintain or improve resident health status was completed timely. This finding had the potential to affect all 97 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the facility was maintained in a clean and sanitary manner. This affected Nursing Unit One and its 24 residents (#3, #4, #8, #9, #11, #13, #14, #17, #23, #24, #32, #39, #40, #44, #48, #49, #52, #60, #70, #72, #85, #92, #94, and #96) and had the potential to affect all 97 residents residing in the facility.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to timely follow-up on Resident #99's family concern regarding missing items. This finding affected one resident (#99) of three residents reviewed for grievances.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to ensure Residents #51 and #94's pressure ulcer wound care was completed as ordered. This finding affected two residents (#51 and #94) of three residents investigated for pressure ulcers.

Inspectors wroteBased on video surveillance, record review, interview, and facility policy review the facility failed to ensure resident safety was maintained during the use of Hoyer mechanical lifts and failed to ensure Hoyer mechanical lifts were in good working order. This finding affected three residents (#38, #46 and #55) of four residents investigated for Hoyer Mechanical Lifts.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to ensure Resident #51 was provided education for using three incontinence briefs on the resident at one time. This finding affected one resident (#51) of three residents investigated for incontinence care.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were documented on Resident #98's medication administration records (MARS). This finding affected one resident (#98) of seven resident records reviewed for accuracy.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure a clean and home like environment. This affected Resident #62 and all of the other 18 residents, Residents #26, #36, #55, #57, #70, #79, #80, #81, #82, #83, #84, #123, #128, #129, #130, #131, and #132, who resided on the third floor. The facility census was 82.

Inspectors wroteBased on observation and interview the facility failed to ensure call lights were with in reach for all residents. This affected four residents (Residents #12, #17, #32, and #35) of 30 residents initially screened. The facility census was 82.

Inspectors wroteBased on observation, record review and interview the facility failed to provide timely incontinence care to Resident #50, who was dependent on staff for toileting. This affected one of one resident observed for incontinence care. The facility census was 82.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #4 was served and assisted timely with meals. This affected one of eight residents reviewed for food and nutrition.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure the oxygen tubing for Resident #29 was changed per physician order. This affected one of four residents (#18, #29, #50, and #75) who received oxygen on the first floor. The facility census was 82.

Inspectors wroteBased on observation, record review and interview the facility failed to provide adequate staffing for provision of timely incontinence care to Resident #50, who was dependent on staff for toileting. This affected one of one resident observed for incontinence care. The facility census was 82.

Inspectors wroteBased on observation and interview the facility failed to ensure Resident #32 and Resident #17's call lights were functional. This affected two of four residents reviewed for call lights. The facility census was 82.

Inspectors wroteBased on record review and interview, the facility failed to ensure State Tested Nursing Assistants (STNAs) received annual performance evaluations as required. This finding affected two of four STNAs employee files reviewed and had the potential to affect all 82 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents #6, #35, #44 and #52 and/or their representatives were notified in writing of the reason for their discharge to the hospital and failed to notify the Ombudsman of Resident #44's transfer to the hospital. This finding affected four (Residents #6, #35, #44 and #52) of six resident records reviewed for hospitalization.

Inspectors wroteBased on record review and interview, the facility failed to provide bed hold notice information to residents/resident representatives as required. This finding affected three (Residents #35, #44 and #52) of six resident records reviewed for transfers/hospitalizations.

Inspectors wroteBased on record review and interview the facility failed to ensure the facility assessment included contracted nursing services agencies. This had the potential to affect all 95 residents currently living in the facility.

Inspectors wroteBased on record review and interview the facility failed to provide written transfer or discharge notices to residents and their representatives and send a copy to the Office of the State Long-Term Care Ombudsman for transfers to the hospital. This affected three (Residents #51, #32 and #8) of four residents reviewed for hospitalization.

Inspectors wroteBased on record review and interview the facility failed to provided written information of the facility's bed hold policy to the resident or representative upon transfer to the hospital for three residents (Resident #51, #32 and #15). This affected three of four residents reviewed for hospitalization.