Parker Nursing & Rehab Center

Inspectors wroteBased on interview and record review the facility failed to investigate an allegation of misappropriation of resident's funds for 1 of 3 residents (R1) reviewed for misappropriation of property in the sample of 7.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident received a diet as ordered, including failure to implement and communicate an ordered diet alternative. This resulted in a significant, unplanned weight loss of 11.1% for 1 of 4 residents (R13) reviewed for significant weight loss in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received the correct portion size for the noon meal. This applies to all 63 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the dish machine and 3-part sink was sanitizing at the appropriate concentration. This applies to all 63 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to have a system in place to verify Certified Nursing Assistants (CNAs) have received the required 12 hours training yearly. This applies to all 63 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure as needed (PRN) psychotropic medications had a stop date for 4 of 5 residents (R4, R24, R9 and R49) reviewed for psychotropic medications in the sample of 17.

Inspectors wroteBased on interview and record review the facility failed to treat a resident with dignity and respect for 1 of 17 residents (R4) reviewed for dignity in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was supervised during medication administration for 1 of 17 residents (R20) reviewed for Pharmacy Services in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications as ordered. There were 33 opportunities with 2 errors resulting in a 6.06% error rate. This applies to 1 of 2 residents (R37) observed during medication pass.

Inspectors wroteBased on interview and record review the facility failed to carry out a physician order as prescribed and failed to increase a residents antipsychotic medication contributing to a significant medication error. This failure resulted in a R10 missing 48 doses of the medication increase. This applies to 1 of 5 residents (R10) reviewed for unnecessary medications in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that staff performed proper hand hygiene after removing gloves during wound care to prevent cross contamination for 1 of 17 residents (R2) reviewed for infection control in the sample of 17.

Inspectors wroteBased on interview and record review the facility failed to ensure resident's were free from physical abuse for 2 of 3 residents (R1 and R2) reviewed for Abuse in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to identify and investigate an allegation of sexual abuse for two residents (R1 and R3); and failed to protect (R1 and R3) from any further possible alleged sexual abuse. These failures led to R1 and R3 to withdraw from socialization and daily activities. R1 and R3 remained in their rooms to avoid contact with the alleged perpetrator (R2). These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 05/26/2025 when R1 and R3 reported R2 was making sexually explicit remarks to them. The allegations were not investigated immediately and R2 had continued access to R1 and R3. R1 and R3 remained fearful and caused R1 and R3 to withdraw socially in an effort to avoid R2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy and procedures for discharge planning for three residents (R1, R2, and R3) and unplanned discharge for three residents (R1, R4, and R5) of four residents reviewed for discharge in the sample of six.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's bed was in the low position and the mat was on the floor to prevent injury from falling out of bed. This applies to 1 of 3 residents (R3) reviewed for safety in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to provide evening snacks for seven of seven residents (R7, R8, R15, R28, R33, R45, R55) reviewed for evening snack provision in the sample of 32 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one allegation of abuse was immediately reported to the facility abuse coordinator for one of one resident (R19) reviewed for abuse in the sample of 32.

Inspectors wroteBased on observation and record review, the facility failed to investigate an allegation of abuse for one of one resident (R19) reviewed for abuse, in the sample of 32.

Inspectors wroteBased on interview and record review the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital, for two of four residents (R53 and R56) reviewed for bed holds, in the sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to perform a PASRR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for two of two residents (R19 and R54) reviewed for PASRR screening, in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative services were being provided for one of two residents (R9) reviewed for restorative and range of motion in a sample of 32.

Inspectors wroteBased on interview and record review the facility failed to provide medications as ordered for one of five residents (R40) reviewed for medication administration, in a sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to donn personal protective equipment during cares for two of 12 residents (R7, R27) reviewed for enhanced barrier precautions in a sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's Power of Attorney (POA) was notified post fall for one of three residents (R2) reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were assessed after a fall per policy and interventions were implemented to prevent further falls for one of three residents (R2) reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was accurate and completed per policy for one of three residents (R2) reviewed for falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure wounds were cleansed and PPE (personal protective equipment) was worn in a manner to prevent cross contamination for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to give showers to three (R1, R2, and R3) of three residents reviewed for activities of daily living in a sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required thickened liquids had access to fluids at night for two of four residents (R1, R2) reviewed for hydration on the sample list of 9. Findings Include: R1's May 2024 Physician Orders documents an order for Honey thick liquids. R2's May 2024 Physician Orders document an order for nectar thick liquids. On 5/2/24 at 5:32 am, V5, CNA (Certified Nursing Assistant), stated R1 and R2 both require thickened liquids. V5 stated the nurses ran out of thickener, therefore, neither R1 or R2 were able to have liquids during the night. V5 explained the thickener is kept in the kitchen and the kitchen is locked up at night, so if the nurse doesn't have thickener, then R1 and R2 don't get liquids. V5 stated R1 usually drinks all night long. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a non-pressure wound treatment was completed for 1 of 3 residents (R1) reviewed for quality of care in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for two (R11 and R12) of four residents reviewed for abuse in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a comprehensive care plan for one (R54) of 19 residents reviewed for care planning in the sample of 31.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure enteral feeding bottles were marked with the date/time that the bottles were changed/started for two of two residents (R11 and R37) residents reviewed for tube feedings, in a total sample of 31 residents. FINDS INCLUDE: Facility policy, entitled Guidelines for Enteral Feeding: Adult, dated 7/3/23, document, 3) Maximum formula hang time is Closed System 24 hours; and 5) Closed System-Closed system bottles and tubing must be changed every 24 hours for bolus feeding, resident may be disconnected by the licensed nurse and the tubing capped between feedings. Bottles/containers and feeding tubing must be changed every 24 hours. On 2/20/2024, at 10:45 AM., R37's enteral feeding bottle was not dated/timed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to address pharmacy medication recommendations for two (R31 and R49) of nine residents reviewed for psychotropic medications in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have appropriate indications for the use of antipsychotic/psychotropic medications, failed to identify target behaviors on the consent forms, and failed to attempt Gradual Dose Reductions for three residents (R1, R31, R49) of five residents reviewed for unnecessary psychotropic medications in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure local hospice service documentation was included in one (R49) of one resident reviewed for hospice services in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent physical abuse for three (R3, R4 and R5) of four residents reviewed for abuse in a sample of nine.

Inspectors wroteBased on interview and record review, the facility failed to have sufficient nursing staff on 12/8/23. This failure resulted in cares not being provided timely, and R3 becoming tearful to staff, crying, and stating she feels like a burden.

Inspectors wroteBased on interview and record review, the facility failed to verify a Certified Nursing Assistant (V4) was certified before working alone on 12/8/23. This failure has the potential to affect all 54 residents in the building.

Inspectors wroteFacility Failures resulted in two deficient practices. A. Based on interview and record review, the facility failed to provide transportation to appointments for eight (R14, R2, R3, R1, R17, R16, R5, and R6) of nine residents reviewed for transportation/appointments in a sample of 17. B. Based on observation, interview, and record review, the facility failed to carry out resident's activities of daily living on 12/8/23. This failure resulted in a delay of residents getting out of bed, getting dressed, incontinent cares, every two-hour checks on residents were not done, and call lights couldn't be answered in a timely manner. This failure also resulted in R3 becoming tearful to staff, crying, and stating she feels like a burden.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow a resident to smoke for two (R1 and R3) of three residents reviewed for smoking in a sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to provide showers on 12/8/23 for six (R7-R12) of six residents reviewed for showers on 12/8/23 in a sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide catheter care for one (R2) of three residents reviewed for catheter cares in a sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to set up/reschedule a dental appointment for one (R1) of one residents reviewed for dental services in a sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep a door closed and move a COVID-19 positive resident to a private room for one (R4) of three residents reviewed for infections in a sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to have a certified Infection Preventionist. This failure has the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of misappropriation of property for two of four residents (R4 and R5) reviewed for misappropriation of property in the sample of seven. Findings Include: The facility's Drug Diversion-Reporting and Response policy, undated, documents the following: It is the practice of the facility to provide guidelines for the identification, reporting and investigation of suspected drug diversion by any employees, residents, or visitors. Drug diversion is the intentional and without proper authorization, using or taking possession of a prescription or a non-prescription medicine or biological from the supply intended for use by the facility staff for the facility residents. Examples of Drug Diversion: A. Medication Theft, B. Using or taking a medication without a valid order or prescription, C. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from involuntary seclusion for one of one residents (R1) reviewed for involuntary seclusion in a sample of seven.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of involuntary seclusion to the Administrator immediately for one of six residents (R1) reviewed for abuse in a sample of seven.

Inspectors wroteBased on interview and record review, the facility failed to establish a system for the reconciliation of controlled drugs for two of four residents (R4 and R5) reviewed for controlled drugs in a sample of seven. Findings Include: The facility policy named, Controlled Substances, with no date, documents, To maintain individual records of receipt and distribution of all controlled drugs in sufficient detail to enable an accurate reconciliation. Controlled substance shall be securely stored, and precautionary measures taken to prevent misuse. 6.) Records shall be maintained by authorized nursing personnel of all scheduled II drugs administered. 7.) An individual Schedule II record in the form of a declining inventory will be initiated when the schedule II drug is delivered to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to deliver resident mail for seven (R1 through R5, R10, and R11) of seven residents reviewed for resident rights in the sample of 17. This failure has the potential to affect all 63 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement their Abuse Prevention policy and procedures after report of an allegation of verbal abuse for one (R2) of four residents reviewed for abuse in the sample of 17. These failures have the potential to affect all 63 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to report a verbal allegation of abuse for one (R2) of three residents reviewed for abuse in the sample of 17. This failure has the potential to affect all 63 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to investigate a reported allegation of verbal abuse for one (R2) of three residents reviewed for abuse in the sample of 17. This failure has the potential to affect all 63 residents currently residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to be administered in a manner to ensure implementation of the facility's Abuse Prevention Program Policy and Procedures and in a manner that provides oversite and leadership to the residents and staff. V1 (Administrator in Training) failed to respond to reported allegations of abuse and misappropriation. These failures affected three of nine residents (R50, R58, and R60) reviewed for abuse in the sample of 11 and have the potential to affect all 57 residents residing in the facility.