Parkside at Budd Terrace Operating Company LLC

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that Minimum Data Set (MDS) Assessments were completed and transmitted to the Center for Medicare and Medicaid Services (CMS) system within 14 days of completion for seven resident (Resident (R) 56, 204, 248, 425, 426, 457 and 459) out of seven residents reviewed for accuracy of assessments. This failure prevented the transmission of resident-specific information used for payment, quality measures, and ongoing clinical data analysis.

Inspectors wroteBased on observations, record review, staff interviews, and review of facility policy, the facility failed to ensure 32 out of 33 Agency Nurses and 83 out of 83 in-house staff nurses were competent to provide Total Parenteral Nutrition (TPN) related care and services to residents residing in the facility, including one Resident (R) R311 of two residents in the facility receiving TPN. The facility's failure to ensure nursing staff was competent related to the administration of TPN created the potential residents to experience a decline in physical status.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure informed consent was obtained for the use of psychotropic medications for one (Resident (R) R49) out of five residents reviewed for unnecessary medication. The deficient practice created the potential for this and other residents to receive medication not necessary or desired related to their psychiatric/mental health care.

Inspectors wroteBased on review of facility policy, record review, and resident and staff interviews, the facility failed to ensure the resident record reflected the correct code status for cardiopulmonary resuscitation (CPR) for one (Resident (R) R49) out of five residents reviewed for advance directive in the sample of 63 residents. The facility's failure to ensure R49's record accurately reflected her chosen code status created the potential for CPR to not be performed as requested for this and other residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure one (Resident (R) R49) out of five residents reviewed for unnecessary medication was free from unnecessary medications. The facility's failure to ensure R49 was free from unnecessary chemical restraints created the potential for this and other residents to receive medication not necessary or desired related to their psychiatric/mental health care.

Inspectors wroteBased on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to complete quarterly Minimum Data Set (MDS) Assessments not less than once every 3 months, for one resident (Resident (R) 56) out of seven residents reviewed for accuracy of assessments in the sample of 63 residents. This failure prevented the transmission of resident-specific information used for payment, quality measures, and ongoing clinical data analysisFindings include:Review of the RAI Manual indicated, Policy interpretation and implementation: Omnibus Budget Reconciliation Act (OBRA) required MDS assessments are federally mandated and therefore must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include Quarterly Assessments. [...]

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to complete a base line care plan for three (Residents (R)98, R99, and R198) of 63 sampled residents reviewed for base line care plans. The failure had the potential to affect the residents' medical, nursing, mental, and psychosocial needs not being met.

Inspectors wroteBased on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to develop person-centered, comprehensive care plans with measurable goals and interventions for one resident (Resident (R) 162) of one resident reviewed for care plans out of a sample of 63 residents. The failure placed R162 at risk for skin breakdown due to incomplete and/or inconsistent care to prevent pressure ulcers.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure services were provided in accordance with professional standards of practice for one (Resident (R)15) of 63 residents sampled. Specifically, nursing staff failed to follow physician's orders for nephrostomy tube site care. The deficient practices placed the resident at risk for infection and compromised skin integrity.

Inspectors wroteBased on staff interviews, and record review, the facility failed to provide Activities of Daily Living (ADL) care, specifically bathing services, in accordance with the residents' needs and the facility's established schedule for three (Residents (R) 306, 76 and 299) of 12 residents reviewed for bathing in the sample of 63 residents, placing the residents at risk for poor hygiene and decreased quality of life.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to provide an ongoing activity program to meet the individual interests and needs to enhance the quality of life for two of two residents (Residents (R) 349 and R299) reviewed for activities out of a total sample of 63 residents. This deficient practice had the potential to negatively affect the quality of life for the affected residents.

Inspectors wroteBased on observations, resident and staff interviews, record review and review of facility policy, the facility failed to ensure splints were consistently applied for two Residents (R)11 and R299) out of three residents reviewed for positioning and mobility. The facility's failure to ensure splints were applied consistently as ordered for these residents created the potential for the residents to experience a decline in range of motion (ROM).

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure an admission weight was obtained for one resident (Resident (R) 224) out of eight residents reviewed for nutrition. The failure to obtain an initial baseline weight for residents could cause the facility to not accurately determine weight loss or gain during the resident's stay.

Inspectors wroteBased on observations, record review, resident and staff interviews, review of facility policy, the facility failed to ensure two Resident (R) R76 and R311 out of three residents reviewed for Intravenous (IV) Nutrition (i.e., Total Parenteral Nutrition (TPN)) received appropriate care related to the administration of their TPN. The facility's failure to ensure appropriate administration of TPN for R76 and R311 created the potential for these residents to experience a decline in physical status.

Inspectors wroteBased on observations, record review, staff interviews, and review of facility policy, the facility failed to ensure bed rails were necessary and a consent was obtained prior to the use of bed rails for two (Residents (R)11 and R299) out of eight residents reviewed for accident hazards in the sample of 63 residents. The facility's failure to ensure bed rails were necessary for these residents created the potential for these and other residents to experience potential negative outcomes such as becoming entrapped in bed rails.

Inspectors wroteBased on observations, record reviews, staff interviews, and facility policy reviews, the facility failed to ensure a medication error rate of less than five percent. There were four errors from 26 opportunities for one of eight residents (R) (R311) observed, for a medication error rate of 15.38 percent. The facility's failure to ensure a medication error rate of less than five percent created the potential for R311 to experience negative physical effects related to medication errors.

Inspectors wroteBased on staff interviews, record review, and review of facility policy, the facility failed to ensure one resident (R) (R311) out of eight residents reviewed for medication errors was free from a significant medication error. The facility's failure to ensure that R311 was free from significant medication errors created the potential for the resident to experience negative physical effects related to the medication errors.

Inspectors wroteBased on observations and staff interviews, record review, and review of facility policy, the facility failed to ensure infection control practices were followed for one (Resident (R)311) of eight residents observed during medication administration. Specifically, the nurse administering the resident's medications failed to sanitize her hands and change her gloves after administering oral and inhaled medications, and before administering medication through a Peripherally Inserted Central Catheter (PICC) line. The facility's failure to ensure proper infection control during medication administration created the potential for cross-contamination and infection.

Inspectors wroteBased on observations, resident and staff interviews, and the facility's policy titled, Safe and Homelike Environment, the facility failed to ensure the residents' living area was safe, clean, and comfortable in four of 165 rooms (Rm 515, RM [ROOM NUMBER], RM [ROOM NUMBER], and RM [ROOM NUMBER]). The facility also failed to ensure the Packaged Terminal Air Conditioner (PTAC) unit filters were free of buildup and debris and failed to ensure that a broken mirror was not stored on the floor in one of six Central bath areas.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled Coordination with PASAAR Program, the facility failed to provide Preadmission Screening and Resident Review (PASARR) Level II for two of six residents (R) (R54 and R75) with qualifying diagnoses.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to ensure ADL care was provided for three of 59 sampled residents (R) (R36, R61, and R75) related to not receiving showers/baths, fingernails care and ADLs care.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled, Resident Self-Administration of Medications and Medication Storage, the facility failed to adequately assess two of 59 sampled residents (R) (R56 and R515) for self-administration of medication; failed to ensure one room was free from accident hazards. Specifically, medication was found in an unoccupied room (room [ROOM NUMBER]) on the second floor. The deficient practice had the potential to cause serious safety issues for residents, staff and visitors.

Inspectors wroteBased on observations, staff, resident, and resident family interviews, record review, and review of the facility's policy titled, Oxygen Concentrator, the facility failed to ensure physician orders for oxygen (O2) therapy were followed for two of eight residents (R) (R43 and R564) receiving oxygen. The deficient practice had the potential to cause abnormal respiratory function and adverse clinical outcomes.

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of the facility's policy titled Pain Management, the facility failed to ensure adequate pain management for two of 59 sampled residents (R) (R371 and R43).

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policies titled Medication Administration, the facility failed to ensure a medication error rate of less than five percent. There were five errors from 40 opportunities observed for a medication error rate of 7.5 percent. This deficient practice had the potential to place resident (R) R12 at risk of medical complications and a diminished quality of life. Findings Include: Review of the facility's undated policy titled Medication Administration, revealed the Policy section included, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review and review of the facility's policy titled, Residents' Rights & Responsibilities, the facility failed to ensure call lights were answered and care provided for one of three residents (R) (R1). Specifically, the facility failed to ensure R1 care needs were met after the initiation of the call light system.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled, Residents' Rights & Responsibilities, the facility failed to ensure one of three residents (R) (R1) the choice of time and preference for showers.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policy titled, Medication Administration, the facility failed to follow professional standards of care for one of 26 Residents (R) (R134). Specifically, the facility failed to transfer a physician ordered medication to the Electronic Medical Record (EMR) system and to the Medication Administration Record (MAR).

Inspectors wroteBased on interviews, record review, and review of the facility's policy titled, Physician Verbal Orders, the facility failed to ensure a telephone order for one of 31 sampled Residents (R) (R290) were transcribed into the Electronic Medication Administration Record (EMAR) system which resulted in R290 not receiving the physician ordered medication.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policies titled, Fall Prevention and Fall Management, the facility failed to ensure a resident that required two-person assistance received adequate supervision during activities of daily living (ADL) care for one of four Residents (R) (R231) reviewed for accidents. This failure resulted in R231 falling from bed to the floor, sustaining neck pain and being transferred to the hospital.

Inspectors wroteBased on observation, staff interview, record review and review of the facility's policy titled, Oxygen Management, the facility staff failed to maintain proper storage of a CPAP (continuous positive airway pressure) mask when not in use for one of one Resident (R) (R134) reviewed for oxygen use.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Medication Storage Rooms and Medication Carts, the facility staff failed to store physician ordered medications in a locked compartment when unattended for two of six medication carts in the facility. The facility census was 118.

Inspectors wroteBased on record review, review of the policy titled Reporting Abuse Allegations and staff interviews, the facility failed to ensure that the Abuse Policy and Procedures were current and implemented, which had the potential to affect all residents. Substandard Quality of Care was identified related to Develop/Implement Abuse/Neglect Policies. The census was 115.

Inspectors wroteBased record review, staff interview, review of the Administrator Job Description, review of grievance files and Resident Council meeting minutes for 2023, facility Administration failed to ensure there was an up-to-date and effective Abuse Prevention Program, that consistently reported allegations of abuse by residents to the State Survey Agency (SSA) and that all staff were educated utilizing the most current Center for Medicare & Medicaid Service (CMS) regulations. The census was 115.

Inspectors wroteBased on interview and review of the policy titled Quality Assurance and Performance Improvement Plan (QAPI) and QAPI minutes, the facility failed to have a Quality Assessment and Assurance (QAA) committee that effectively identified, developed, implemented, and monitored corrective action plans related to Abuse Prevention Policy and Procedure and to ensure that allegations of abuse were reported to the State Survey Agency (SSA). The census was 115.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to ensure that allegations of abuse were reported to the State Survey Agency (SSA) for three of 11 sampled residents (R) (R A, R5, and R12).

Inspectors wroteBased on observations, record review, staff and resident interviews, the facility failed to ensure a care plan was developed for ostomy care for one resident (R) B of 22 sampled residents.