Parkside Homes

Inspectors wroteBased on record review and interview, the facility failed to complete an annual performance review at least once every 12 months for one Certified Nurse Aide (CNA), employed greater than one year.

Inspectors wroteBased on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to the residents of the facility appropriately to prevent the potential for food borne bacteria.

Inspectors wroteBased on observation, interview, and record revise, the facility failed to ensure the walk-in freezer in one of one kitchen of the facility was in clean, safe operating condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete the Care Area Assessment (CAA) analysis related to a Comprehensive Minimum Data Set (MDS), for Residents (R)2, R9, R12, R21, R29, R33, and R38 to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs.

Inspectors wroteBased on interview and record review, the facility failed to inform Resident (R) 1 and R32 and/or their representatives regarding the risks related to psychotropic (alters mood or thoughts) medications.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure Resident (R) 1's as needed (PRN) psychotropic medication (alters mood or thoughts) had a 14 day stop date, or a specified duration with a physician rationale for extended use. Additionally, the facility failed to monitor R25's for target behaviors or side effects of the psychotropic medications.

Inspectors wroteBased on record review and interview, the facility failed to notify the State Ombudsman of two resident discharges to the hospital, regarding Resident R1 and R3, as required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a written baseline care plan to Resident (R) 32, and R37.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received assistance with activities of daily living (ADL) including nail care for Resident (R)1, and R32.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to monitor Resident (R) 38's nutritional and hydration status during an acute change of condition. The facility failed to monitor for complications related to R2's multiple bruises and a skin tear.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to implement adequate infection control practices related to respiratory equipment for Resident (R) 1 and R37, and hand hygiene during incontinence care for R2.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure Resident (R)1's bed was in safe condition.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the facility laundry.

Inspectors wroteBased on observation, record review, and interview, the facility failed to display accurate, publicly accessible, and identifiable staffing information, on a daily basis, for the 30 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by failing to ensure the lid of the dumpster was kept closed.

Inspectors wroteThe facility reported a census of 38 with three residents included in the sample. Based on interviews and record review the facility failed to prevent a medication error when Licensed Nurse C did not follow the physician order and incorrectly administered five times the ordered amount of Ativan to Resident (R)1, who was on hospice.

Inspectors wroteThe facility reported a census of 34 resident, with 12 sampled, including seven residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for five residents. The facility failed to include fall prevention interventions on the care plan for Resident (R)238, who fell and sustained deep lacerations to his face, which required transfer to the ER and sutures/stitches and glue as treatment. The facility further failed to implement new care plan interventions to prevent further falls for R31 and failed to investigate the fall experienced by R24. [...]

Inspectors wroteThe facility reported a census of 34 residents. Based on observation, interview, and record review, the facility failed to ensure that meals were served at safe and appetizing temperature. Residents (R) 24 and 35 complained of cold food temperatures at meals.

Inspectors wroteThe facility reported a census of 34 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.

Inspectors wroteThe facility reported a census of 34 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to the maintaining a sterile (free from germs or microorganisms) field with a peripherally inserted central catheter (PICC-a form of access directly into the bloodstream via a vein that can be used for a prolonged period of time) dressing change for Resident (R) 238 and Dietary Staff G lacked proper hand hygiene during dining room service. Additionally, staff improper hand hygiene with catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. [...]

Inspectors wroteThe facility reported a census of 34 residents. Based on interview and record review the facility failed to ensure staff adhered to the principles of antibiotic stewardship through monitoring for the appropriate use of antibiotics prescribed for residents to prevent antibiotic resistance and spread of multidrug resistant organisms within the facility.

Inspectors wroteThe facility reported a census of 74. The sample included 18 residents. Based on observations, record reviews, and interviews, the facility failed to address and resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included- - A review of the facility's Resident Council Minutes from 09/2023 through 09/2024 indicated the council had recurring concerns with the food temperatures. The 10/19/23 Resident Council Minutes documented concerns that corn dogs were being served cooked on the outside but remained icy in the inside. The 10/18/24 Resident Council Minutes documented concerns that foods that were shelf-stable at room temperature were being served cold. [...]

Inspectors wroteThe facility reported a census of 34 residents with 12 residents sampled. Based on observation, interview, and record review, the facility failed to ensure one of the four medication carts observed were locked while unattended. This deficiency had the potential to affect 14 residents located on the main campus.

Inspectors wroteThe facility reported a census of 34 residents, with 12 residents sampled, including review for advanced directives (a written document, which indicates the medical decisions for health care professionals when the person could not make their own decisions). Based on interview and record review, the facility failed to ensure one resident's advanced directives were thoroughly completed. Resident (R)16 had a Do Not Resuscitate (DNR- or no code, a legal document or order that means the person does not desire cardiopulmonary resuscitation [CPR is an emergency lifesaving procedure performed when the heart stops beating] in the event of cardiac arrest), which was only signed by a physician.

Inspectors wroteThe facility reported a census of 34 residents with 12 residents sampled, including one resident reviewed for notification of change. Based on observation, interview, and record review, the facility failed to ensure the resident/resident's representative for Resident (R) 35, the right to be informed when the resident had a new order for an anti-psychotic (class of medications used to treat major mental conditions which cause a break from reality) medication dosage change.

Inspectors wrote- Review of the Electronic Health Record (EHR) revealed R10 had the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), west Nile virus (WNV - a virus that is spread by mosquitos that can cause critical illness that can include encephalitis [inflammatory condition of the brain]), cataract (clouding of the lens of the eye), contracture (abnormal permanent fixation of a joint or muscle) and motor neuron disease (a condition that causes weakness in the muscles, leading eventually to paralysis). Review of the 6/20/24,admission Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. [...]

Inspectors wroteResident #3 Activities of Daily Living Resident (R) pertinent diagnoses from (date) physician's order EMR documented: PAIN, UNSPECIFIED(R52), UNSPECIFIED DISORDER OF EYE AND ADNEXA(H57.9), GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS(K21.9), DRY EYE SYNDROME OF UNSPECIFIED LACRIMAL GLAND (H04.129), IRON DEFICIENCY(E61.1), MYALGIA, UNSPECIFIED SITE(M79.10), ANEMIA, UNSPECIFIED(D64.9), ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITH UNSPECIFIED ANGINA PECTORIS (I25.119), HYPOKALEMIA(E87.6), RESTLESS LEGS SYNDROME(G25.81), VITAMIN DEFICIENCY, UNSPECIFIED(E56.9), PULMONARY HYPERTENSION, UNSPECIFIED(I27.20), MIXED HYPERLIPIDEMIA(E78.2), NONRHEUMATIC AORTIC VALVE DISORDER, UNSPECIFIED(I35.9), OVERACTIVE BLADDER(N32.81), LONG TERM (CURRENT) USE OF ANTICOAGULANTS(Z79.01), OTHER KYPHOSIS, SITE UNSPECIFIED(M40.299), OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC)(G47.33), CHRONIC [...]

Inspectors wroteThe facility reported a census of 34 residents with 12 residents selected for review. Based on observation, interview, and record review, The facility failed to accurately complete the Minimum Data Set for three residents, Resident (R) 35 related to falls and injections, R31 related to the use of a Foley catheter (tube inserted into the bladder to drain urine into a collection bag) and oxygen, and R 24 related to falls. This placed the residents at risk for uncommunicated care needs.

Inspectors wroteThe facility reported a census of 34 residents with 12 residents sampled that included one resident reviewed for baseline care plan. Based on interviews, observations, and record review, the facility failed to develop a person-centered baseline care plan for one resident, Resident (R) 238. This deficient practice had the potential to lead to uncommunicated needs and accidents.

Inspectors wroteThe facility had a census of 34 residents, the sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan with interventions to address the enhanced barrier precautions for Resident (R)12's wounds, to ensure infection control precautions, which placed other residents at risk.

Inspectors wroteThe facility reported a census of 34 residents with 12 residents selected for review. Based on observation, interview and record review, the facility failed to review and revise the comprehensive care plan for two residents, Residents (R) 24 and R31 related to falls and accident hazards. These deficient practices had the potential to lead to uncommunicated needs that would negatively affect the physical and psychosocial well-being of the residents.

Inspectors wroteThe facility reported a census of 34 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to assess and address skin issues including open areas to her bilateral legs and edema (swelling resulting from an excessive accumulation of fluid in the body tissues) for Resident (R) 12. This deficient practice had the potential to place R12 at an increased risk for development of additional medical problems.

Inspectors wrote- R3's Electronic Medical Record (EMR) documented diagnoses of atherosclerotic heart disease (heart disease caused by narrowing of the vessels on the heart), pulmonary hypertension (high blood pressure of the great vessels in the chest), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), obstructive sleep apnea (OSA - a disorder in which the upper airways of the throat become constricted during sleep and can cause periods of apnea [absence of breathing]), and atrial fibrillation (rapid, irregular heartbeat). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The assessment documented that R3 utilized a wheelchair or walker and required maximum/moderate assistance for personal hygiene, toileting, and bathing and received oxygen. [...]

Inspectors wroteThe facility reported a census of 34 residents with 12 residents sampled. Based on interview and record review the facility failed to provide the pneumococcal vaccine (vaccine designed to prevent pneumonia [inflammation of the lungs which can be debilitating or lethal in the elderly]) declination form to four of the five residents reviewed. (Resident (R) 3,11, 17 and 238). Additionally, the facility failed to provide R3 with the influenza vaccine (a vaccine designed to prevent influenza [highly contagious viral infection]) declination form for one of the five residents reviewed.

Inspectors wroteThe facility reported a census of 38 residents with two residents reviewed for risk of elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without knowledge of staff). Based on observation, interview, and record review, the facility failed to provide adequate supervision and a safe environment, as free of accident hazards as possible, to prevent the elopement of cognitively impaired and independently mobile Resident (R)1. On 03/31/24 at approximately 11:30 AM, R1 attempted to exit the front door of the house she resided in without success, and then exited the house into the gated courtyard, followed by staff. R1 was agitated and voiced she wanted to leave. After sitting outside for approximately 45 to 60 minutes with staff, the staff accompanied R1 inside the main building. [...]

Inspectors wroteThe facility had a census of 38 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to store paints and glue securely and failed to lock an unalarmed exit door during extremely cold weather which was accessible to two cognitively-impaired independently mobile residents. The facility further failed to investigate and identify causative factors and implement meaningful resident centered interventions to prevent falls for Resident (R)20, R25, and R29. This placed the affected residents at risk for falls and fall related injuries.

Inspectors wroteThe facility had a census of 38 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to store drugs and biologicals under proper temperature controls in one of two medication rooms. This placed the affected residents at risk for ineffective medication regimen.

Inspectors wroteThe facility had a census of 38 residents. The sample included 14 residents with three reviewed for pressure injuries. Based on observation, record review, and interview the facility failed to notify the physician when Resident (R) 29 had a wound on his left heel. This placed R29 at risk for delayed treatment and impaired wound healing.

Inspectors wroteThe facility had a census of 38 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to review and revise Resident (R) 20, and R25's plans of care with resident centered interventions to prevent falls and failed to update R29's care plan for pressure injury to the heel. This deficient practice placed the residents at risk of uncommunicated care needs as related to falls and skin breakdown.

Inspectors wroteThe facility had a census of 38 residents. The sample included 14 residents with five residents reviewed for pressure injuries. Based on observation, record review, and interview, the facility failed to ensure one of five residents received necessary treatment and services to promote healing for Resident (R) 29's left heel pressure injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). This placed R29 at risk for further injury, delayed healing and wound related pain.

Inspectors wroteThe facility had a census of 38 residents. The sample included 14 residents with three reviewed for bowel and bladder and urinary tract infection (UTI-infection of any part of the urinary system). Based on observation, record review, and interview the facility failed to provide appropriate treatment and services to prevent UTIs when staff failed to change gloves during perineal (genital areas) care for Resident (R) 29, who had a history of UTIs. This placed R29 at risk for recurring UTI and related complications.

Inspectors wroteThe facility had a census of 38 residents. The sample included 14 residents, of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain a stop date for Resident (R) 17 for use of as needed (PRN) antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication, which placed R17 at risk of receiving unnecessary psychotropic (medication that affects a person's mental status) medication.