Parks Health Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring and administering of all medications to meet the needs of each residents, for 1 of 4 medication carts inspected for controlled medication reconciliation and for 2 of 10 (Residents #24 and #46) residents reviewed for pharmacy services in that: MA B did not document the administration of a controlled medication on the individual controlled medication records after administering it to Residents #12, #13, #15, #21 and #42 on 01/14/2026. MA A failed to administer prescribed medications to Resident #24 and #46 on 1/13/26 when she left medications at bedside unattended. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assure drugs and biologicals were stored properly in 1 of 2 medication rooms and failed to store all drugs and biologicals in locked compartments for 1 of 2 treatment carts and 1 of 4 medications carts in that: The refrigerator in the medication room contained 1 opened multi-use vial of Tuberculin PPD (Purified Protein Derivative) that had been opened but no open date was found on it. The treatment nurse failed to ensure the treatment cart was locked when it was left unattended. MA A failed to ensure the medication cart was locked when it was left unattended. These failures could place clients at risk for drug diversion or accidental ingestion and place residents and staff at risk for not getting an accurate screening for Tuberculosis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor and appearance and food and drink that was palatable, attractive and at a safe and appetizing temperature from 61 of 63 residents in the facility. 1. The facility failed to ensure food was not held on the steam table longer than necessary for meal service. 2. The facility failed to ensure pureed foods were prepared according to recipes provided by the dietitian and cooked with large volumes of water. These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation and food storage. 1. The facility failed to ensure temperatures were recorded for the refrigerators, dry storage, warmer oven, and freezers. 2. The facility failed to ensure stored foods were properly stored, labeled, and dated. 3. The facility failed to ensure dietary staff properly wore facial hair restraints. 4. The facility failed to properly clean the blender used to puree food between uses. 5. The facility failed to discard spoiled/out-of-date items. 6. The facility failed to prevent dishes and utensils from being stored face up (open to air contamination). 7. The facility failed to ensure Dietary Staff used proper hand hygiene. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 6 residents (Resident #15 and Resident #29) reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan regarding oxygen therapy for Resident #15 and Resident #29. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (of 7 residents Resident #15 and Resident #29) reviewed for oxygen management. 1. The facility failed to ensure Resident #15 had an order for oxygen. 2. The facility failed to ensure Resident #29 had an order for oxygen and an Oxygen in Use sign on the doorway. These failures could place residents at risk of not receiving appropriate respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide daily meals at regular times for 2 of 2 meals (breakfast and lunch) observed for timely meal service. The facility failed to serve the breakfast and lunch meals on 10/15/24, at the specific times posted. This failure could place residents at risk of increased hunger, thirst, frustration, and decreased feelings of self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents and failed to ensure medications were disposed of when expired for 1 of 3 nurses carts inspected for medication storage. The nurse cart for used for halls one and three had four insulin pens and one insulin vial that had expired as indicated by the manufacturer's recommendations. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.

Inspectors wroteBased on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the facility's only kitchen were stored and sealed appropriately. These failures could place residents at risk for food-borne illness, and food contamination.

Inspectors wroteBased on interview, and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 2 of 7 residents (Residents #13 and #23) reviewed for accurate medical records. The facility failed to document the pulse of the resident's when the physician's orders documented hold parameters for Residents #13 and #23. This failure placed facility residents at risk for incorrect medication administrations due to misinformation by incomplete and inaccurate medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #2, #12 and#66) of 5 residents reviewed for infection control. CNA B failed to change her gloves when going from dirty to clean during peri-care and assisting Resident #12 with her ADLs. CNA B failed to wash her hands after she was finished assisting Resident #12 with personal care and before going on to assist someone else. CNA C failed to wash her hands prior to putting gloves on and assisting Resident #2 with personal care. CNA C failed to change her gloves when going from dirty to clean during peri-care and assisting Resident #2 with her ADLs. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents and ensure medications were dated when opened for 1 of 3 nurses' carts (cart for hall 100), 1 of 4 medication carts (cart used for hall 100) and for 1 of 2 medication rooms (Medication room on hall 100) and disposed of when expired and for 1 of 7 residents reviewed Residents (Residents #13) of three residents observed for drug storage in that: The nurses' and medication carts were left unlocked and unsupervised. The medication room had an opened and undated vial of Tuberculin (TB) medication in the refrigerator. The facility failed to ensure Resident #13's 3 vials of breathing treatments were secured. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for three of three residents (Residents #1, #37, #42) reviewed for food meeting residents' needs, in that: The DM did not puree eggs and ham to a puree consistency as required for Residents #1, #37, #42 who were ordered a pureed diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to choking, poor intake, and/or weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 4 Medication Carts and 1 of 2 Medication Storage Rooms reviewed for pharmacy services. 1. The facility failed to ensure Medication Cart #1 did not include expired Melatonin 1 mg tablets, Pepcid AC 10 mg tablets, Vitamin D3 capsule, Mag Oxide 400 mg tablets, and Timolol Maleate eyedrops. 2. The facility failed to ensure Medication Cart #2 did not include expired Med Honey Gel 15 ml tubes, Iodoform Packing Strips, and Benzoin Tincture Sterile Applicators. 3. The facility failed to ensure the Medication Storage Room did not contain expired Pneumovax 23 Polyvalent Vaccines 0.5 ml single-use syringes. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Residents #128) reviewed for care plans. The facility failed to ensure Resident #128 had a care plan in place to address urinary tract infection. This failure could place residents at risk of not receiving individualized care and services to meet their needs.