Parke View Rehabilitation & Care Center

Inspectors wroteBased on observation and interview, the facility failed to ensure dignity of residents when staff enter their rooms without knocking and waiting for acknowledgement to enter. This was true for 5 out of 6 resident rooms observed during afternoon CNA rounds. This deficient practice placed residents at risk of embarrassment and diminished sense of self-worth.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 8 residents (Resident #8) reviewed for accuracy of MDS assessments. This deficient practice created the potential for residents to have their mental health needs not met due to inaccurate assessments.

Inspectors wroteBased on record review, Idaho Medicaid Plan Benefit 16.03.26.475.03, observation, and staff interview, it was determined the facility failed to update a residents' Level I PASRR (Preadmission Screening and Resident Review) with new diagnosis which required further screening, a Level II PASRR to be completed. This was true for 3 of 4 residents (#7, #8, and #13) whose PASRR records were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and cared for or monitored due to inaccurate assessments.

Inspectors wroteBased on the facility routine standing orders, record review and staff interview, it was determined the facility failed to follow the facility bowel care standing order of delivering specific medications when residents do not have BM within 72 hours for 2 of 8 residents (#7 and #10) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 3 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on observation and interviews, it was determined the facility failed to ensure medication carts were locked when unattended. This was observed in 1 of 3 medication carts. This failure created the potential for residents to obtain prescribed medications used for other residents and presented the risk for cross-contamination of medications stored in the cart.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment when staff did not perform hand hygiene prior to providing care from resident-to-resident. This failure had the potential to impact 3 of 3 residents (#5, #17 and #71) observed during resident care, placing them at risk for cross-contamination and infection.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and functional environment. This was true for 2 of 2 residents (#2 and #76) whose sharps containers were observed to be overfilled. This failure had the potential for injury and infections.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents who self-administer medications had been assessed and evaluated for cognitive and physical ability to self-administer medications and reviewed by the Interdisciplinary Team (IDT) prior to residents self-administering medications for two of two residents (Resident (R) 38 and R11) observed self-administering medications. As a result of this deficient practice, medications may or may not actually be correctly administered. Findings below: 1. Review of R38's admission Record located in the electronic medical record (EMR) under the Profile tab revealed an admission date of 01/11/19 and readmission on [DATE] with medical diagnosis including cerebral infarction. [...]

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level I assessment was completed after the resident remained in the facility past the initial 30 day exception for one residents (Resident (R)31 out of one residents out of a total sample of 22 residents reviewed for PASARR level I screenings which had the potential to prevent or delay additional services to a resident that may qualify for a level II.

Inspectors wroteBased on observation, interview, record review, and Fundamentals of Nursing textbook guidance, the facility failed to ensure a physician's order was in place prior to flushing a Foley catheter for one of three residents (Resident (R) 49) reviewed for indwelling urinary catheter care. As a result of this deficient practice there is a potential for introducing bacteria into the closed indwelling urinary catheter system.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure residents received alternative measures prior to installation of side rails, for two of three residents reviewed for side rails (Resident (R) 84 and (R) 26) of 22 sampled residents. The lack of alternative measures and proper assessment could lead to potential restraint or side rail entrapment.

Inspectors wroteBased on observation, interview, manufacturer's instruction review, and policy review, the facility failed to ensure expired mediations were discarded in one of two medication rooms (main medication room on TCU unit) reviewed for outdated medications. As a result of this deficient practice residents may receive medication with decreased potency and effectiveness.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents received information and assistance to exercise their right to formulate an Advance Directive. This was true for 5 of 16 residents (#10, #31, #34, #56, and #65) reviewed for Advance Directives. The deficient practice created the potential for harm should residents' wishes regarding end of life or emergent care not be honored if they were incapacitated.

Inspectors wroteBased on staff interview, review of admission agreement paperwork, and record review, it was determined the facility failed to ensure transfer notices were provided in writing to residents upon transfer. This was true for 1 of 2 residents (Resident #21) reviewed for transfers. This deficient practice had the potential for harm if residents were not made aware of or able to exercise their rights related to transfers.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a bed-hold notice was provided to a resident and/or their representative upon transfer to the hospital. This was true for 1 of 2 residents (Resident #21) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time and may cause psychosocial distress if not informed they may be charged to reserve their bed/room.

Inspectors wroteBased on record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for medication and CPAP (Continuous Positive Airway Pressure) administration. This was true for 1 of 3 residents (Resident #40) reviewed for bowel care . This failed practice created the potential for residents to experience complications related to constipation (Resident #40) if they did not receive the necessary treatment.

Inspectors wroteBased on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to; a) ensure staff stored the nebulizer mouthpiece appropriately after each use and let it dry and b) ensure professional standards of practice were followed for CPAP (Continuous Positive Airway Pressure) administration This was true for 1 of 1 resident (Resident #64) reviewed for respiratory care. This failure placed residents at risk of respiratory infections due to the growth of pathogens (organisms that cause illness) in the respiratory equipment and increased respiratory problems if they did not receive the necessary treatment.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure pharmacy labels were on resident medications prior to use. This was true for 1 of 4 residents (Resident #275) reviewed for medication storage and labeling. This failed practice created the potential for residents to receive unidentified or expired medications.

Inspectors wroteBased on observation, staff interview and policy review, it was determined the facility failed to ensure a glucometer used to check blood glucose levels was cleaned after each use. This was true for 2 of 3 residents (#44 and #64) observed for blood glucose testing. This deficient practice created the potential for the spread of infectious organisms from cross contamination which could harm all residents in the facility. The facility's Care of the Blood Glucose Meter Policy, dated 10/14/10, directed staff to clean the outside of the meter per the manufacturer's guidelines, before initial use, and after every patient. On 6/4/19 at 4:35 PM, LPN #3 was observed performing a capillary blood glucose test to Resident #64 using a glucometer. After the completion of the capillary blood glucose test, LPN #3 placed the glucometer inside a plastic cup, removed her gloves and washed her hands. [...]