Parkdale Health and Rehab

Inspectors wroteBased on interviews, document review, and facility policy review, the facility failed to implement a quality assurance and performance improvement program to evaluate and monitor resident falls in the facility. This deficient practice had the potential to affect all residents who currently resided in the facility.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to develop a care plan to address the supplemental oxygen usage for 4 (Residents #1, #8, #11, #23) of 6 sampled residents reviewed for respiratory care and a care plan to address the fall status of 1 (Resident #16) of 4 sampled residents reviewed for accidents.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to conduct neurological assessments following unwitnessed falls for 2 (Resident #16 and Resident #28) of 4 sampled residents reviewed for accidents.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure adequate supervision was provided to maintain safety and prevent potential injury during smoke breaks for 1 (Resident #1) of 4 sampled residents reviewed for accidents. On 05/14/2024 at 11:57 AM, Resident #1 was smoking outside in the designated smoking area with a portable oxygen tank on the back of their wheelchair and, a nearby propane tank. The facility further failed to ensure 2 (Resident #16 and Resident #28) of 4 sampled residents reviewed for accidents received adequate supervision and/or assistive devices to prevent falls.

Inspectors wrote3. An admission Record revealed the facility admitted Resident #11 on 04/16/2024, with diagnoses to include chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, pneumonia, and bronchitis. An admission Minimum Data Set (MDS), with an Assessment References Date (ARD) of 04/22/2024, revealed Resident #11 used oxygen therapy. Resident #11's Order Summary Report, for the timeframe 04/16/2024 to 05/31/2024, did not reveal a physician's order for the resident's use of supplemental oxygen. On 05/13/2024 at 11:50 AM, Resident #11 was observed lying in bed with oxygen tubing on and an oxygen concentrator in the on position, set at two liters per minute. On 05/18/2024 at 9:53 AM, Resident #11 was observed in the hall by the nurses' station. The resident had oxygen tubing on and an oxygen concentrator in the on position, set at two liters per minute. [...]

Inspectors wrote4. An admission Record revealed the facility admitted Resident #21 on 03/21/2023, with a diagnosis to include shortness of breath. Per the admission Record, on 05/10/2024, Resident #21 received a diagnosis of chronic obstructive pulmonary disease and acute respiratory failure with hypoxia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/2024, revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident used oxygen therapy. Resident #21's care plan, initiated on 03/29/2023, revealed the resident had shortness of breath. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to notify the physician after a resident sustained a fall for 1 (Resident #16) of 4 sampled residents reviewed for accidents.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure an appropriate diagnosis was obtained for all psychotropic medications ordered for 2 (Resident #7 and Resident #11) of 5 sampled residents reviewed for unnecessary medication, psychotropic medications, and medication regimen review.

Inspectors wroteBased on interviews and facility policy review, the facility failed to conduct mandatory training for all staff on the facility's quality assurance and performance improvement (QAPI) program. This deficient practice affected all residents who currently resided in the facility

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property for 4 of 7 sample residents were 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. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all allegations of abuse were thoroughly investigated. Specifically, the facility completed a form 359 as a summary for allegations of abuse, but did not have additional evidence of the complete investigation for 4 of 7 sample residents. Resident identifiers: 1, 2, 3 and 7.

Inspectors wroteBased on interview and record review, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, for 1 out of 20 sampled residents, a resident that developed pressure ulcers on both heels did not have the treatment implemented according to the physician's orders. In addition, the resident's left anterior pressure ulcer developed an infection. Resident identifier: 80.

Inspectors wroteBased on interview and record review, the facility failed to inform residents, resident representatives, and resident families of the occurrence of a single confirmed infection of coronavirus disease of 2019 (COVID-19), or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other by 5:00 PM the next calendar day. Specifically, three facility staff members tested positive for COVID-19 and residents, resident representatives, and resident families were not notified of the outbreaks.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 3 out of 20 sampled residents, a resident with orders to follow up with the Orthopedic Surgeon two weeks after discharge from the hospital did not have a follow up and the surgical staples were not removed until four weeks after discharge from the hospital. A resident with a nephrostomy tube did not receive wound care as ordered by the Physician Assistant (PA) professional wound specialist and a resident with a rash and itchy skin was not treated. Resident identifiers: 12, 15, and 80.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident was offered an influenza and/or pneumococcal immunization and that the medical record included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, for 3 out of 20 sampled residents, residents that had consented to the pneumococcal immunization did not have documentation that the pneumococcal immunization was provided. In addition, a resident that had consented to the influenza immunization did not have documentation that the influenza immunization was provided. Resident identifiers: 19, 23, and 24.

Inspectors wroteBased on interview and record review, the facility did not ensure the resident's medical record included documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with the Coronavirus disease of 2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, for 5 out of 20 sampled residents, the facility did not provide the resident or resident representative with education of the benefits and potential risks associated with the COVID-19 vaccination. In addition, the resident's medical record did not include documentation regarding the residents' COVID-19 vaccination refusal or acceptance. Resident identifiers: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the residents right to participate in the development and implementation of his or her person-centered plan of care. Specifically, for 1 out of 20 sampled residents, a resident that was admitted to the facility on [DATE], had not had a care conference and the resident was unsure what the plan of care consisted of. Resident identifier:

Inspectors wroteBased on interview and record review, the Minimum Data Set (MDS) assessment did not accurately reflect the resident's status. Specifically, for 2 out of 20 sampled residents, a resident was incorrectly coded as not having a Traumatic Brain Injury (TBI) and a resident was incorrectly coded as being discharged to the hospital. Resident identifiers:

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, for 2 out of 20 sampled residents, a resident's care plan was left blank in multiple sections and a resident's wound care plan was not updated. Resident identifiers: 16 and 80.

Inspectors wroteBased on interview and record review, the facility did not ensure residents who displayed or were diagnosed with a mental disorder or psychosocial adjustment difficult, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, for 1 out of 20 sampled residents, a resident with a diagnoses of post-traumatic stress disorder and major depressive disorder who expressed adjustment difficulties was not offered behavioral health services. Resident identifier:

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 2 out of 20 sampled residents, a resident's diuretic medication used to treat high blood pressure was not monitored according to the physician's ordered parameters. In addition, a resident's angiotensin-converting enzyme medication to treat high blood pressure was not monitored according to the physician's ordered parameters. Resident identifiers: 2 and 84.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. A GDR must be attempted in two separate quarters, with at least one month between attempts, within the first year in which an individual was admitted on a psychotropic medication or after the facility had initiated such medication, and then annually. Specifically, for 1 out of 20 sampled residents, a resident taking a psychotropic medication that was initiated on 3/30/22, had not received a GDR and the medication was not clinically contraindicated. Resident identifier: 10.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents were free of significant medication errors. Specifically, for 1 out of 20 sampled residents, a resident returning from the hospital missed two doses of a seizure medication that was prescribed by the physician at the hospital. Resident identifier:

Inspectors wroteBased on observation, interview, and record review, the facility did not obtain routine dental services to meet the needs of the resident. Specifically, for 1 out of 20 sampled residents, a resident with missing teeth, gum swelling, reported pain, and had a recommendation from the Speech-Language Pathologist (SLP) was not provided dental services for six months. In addition, the resident had not been scheduled for the extractions and the last dental visit was in November 2022. Resident identifier: 12.

Inspectors wroteBased on observation and interview, it was determined that the facility did not store, prepare, and distribute food in accordance with professional standards for food services safety. Specifically, a staff member was observed not sanitizing or changing gloves while distributing food in the dining room. On 12/12/22 at 12:00 PM, the lunch dining service in the main dining room was observed. a. At 12:05 PM, the Dietary Aide (DA) was observed to serve a resident in the main dining area their lunch tray. The DA was observed to have disposable medical gloves on. The DA was observed to enter the kitchen after serving a resident, adjusted her surgical mask, did not change the gloves or sanitize her hands. b. At 12:10 PM, the DA was observed to serve a resident in the main dining area their lunch tray. The DA was observed to have disposable medical gloves on. [...]

Inspectors wroteBased on observation, interview, and record review it was determined, for 2 of 19 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, facility staff did not obtain additional medical care for four days after a resident fell causing a broken leg above a recent artificial knee. This delay was determined to have occurred at a harm level. Additionally, a resident was transferred by a Certified Nursing Assistant (CNA) who did not lock the wheelchair wheels during the transfer causing the resident to fall. Resident identifiers: 11 and 22.

Inspectors wroteBased on interview and record review, it was determined that the facility did not employ a clinically qualified full-time dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. The Certified Dietary Manager was also working as the maintenance supervisor and was not working full time in the kitchen, and the kitchen supervisor (KS) was not certified.

Inspectors wroteBased on record review and interview it was determined for 1 of 19 sample residents, that the resident was not able to make choices about aspects of their life in the facility, that were significant to the resident. Specifically, a resident was showered during the night shift and was not asked about her preference to shower during the day. Resident identifier: 23.

Inspectors wroteBased on observation, interview, and record review, for 1 of 19 sample residents, it was determined that the facility did not ensure that the resident's environment remained as free of accident hazards as possible. It was also determined that each resident did not receive adequate supervision and assistance devices to prevent accidents. Specifically, facility staff did not ensure the safety of residents transfers, and neglected to use safety devices to prevent falls. Resident identifier: 11.

Inspectors wroteBased on observation and interview it was determined for 2 of 19 sample residents, that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a licensed practical nurse (LPN) was observed not properly cleaning equipment and a medication administration device according to policy and best practices. It was also observed that the LPN did not follow infection control procedures in medication administration. Resident identifiers: 9 and 16.