Parkside Lutheran Home

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 5 of 12 sampled residents (Resident #2, #4, #5, #8, and #41). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, review of professional reference, review of facility policy, and staff interview, the facility failed to ensure safe food practices and failed to maintain a clean and sanitary kitchen environment for 1 of 1 kitchen and 2 of 2 freezers on the Cozy Cottage Unit. Failure to properly store food items and maintain a clean and sanitary kitchen, food preparation, and storage areas has the potential for contamination of food and may result in a foodborne illness to residents, visitors, and staff. Findings Include: The 2022 Food and Drug Administration (FDA) Food Code, Chapter 3-16, Section 3-305.11 Food Storage, stated, . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . Annex 3 Page 100, stated, . 3-305.12 Food Storage, Prohibited Areas. [...]

Inspectors wroteBased on record review, review of facility policy, and staff interviews, the facility failed to identify an incident of verbal abuse for 1 of 1 sampled resident (Resident #8) who was subjected to name calling and sworn at by a staff member. Failure to ensure residents were free from verbal abuse resulted in Resident #8's experiencing emotional distress and placed him and other vulnerable residents at risk of potential and/or continued verbal abuse.

Inspectors wroteBased on record review, review of facility policy, and staff interviews, the facility failed to immediately report an incident of verbal abuse for 1 of 1 sampled resident (Resident #8) subjected to name calling and sworn at by a staff member. Failure to report the incident to the state survey agency (SSA) placed Resident #8 and other vulnerable residents at risk of potential and/or continued verbal abuse.

Inspectors wroteBased on record review and review of facility policy, the facility failed to investigate an incident of verbal abuse for 1 of 1 sampled resident (Resident #8) who was subjected to name calling and sworn at by a staff member. Failure to thoroughly investigate the incident placed Resident #8 and other vulnerable residents at risk of potential and/or continued verbal abuse.

Inspectors wroteBased on observation, record review, policy review, and staff interview, the facility failed to provide medication in accordance with professional standards for 1 of 1 resident (Resident #31) with a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted through the skin and abdominal wall directly into the stomach) observed during medication administration. Failure to accurately transcribe provider's orders may result in adverse health effects.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment and services for 1 of 1 sampled resident (Resident #2) with a pressure ulcer. Failure to complete weekly assessments with measurements of pressure ulcers per facility policy, may result in new pressure ulcers, the deterioration of existing pressure ulcers, and delay healing.

Inspectors wroteBased on observation, record review, policy review, review of a professional reference, and staff interview, the facility failed to provide appropriate toileting for 1 of 2 sampled residents (Resident #31) who required staff assistance with toileting. Failure to provide toileting may result in a loss of dignity and placed the resident at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and at risk for falls and/or injuries.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 2 residents (Resident #2 and #31) in enhanced barrier precautions (EBP). Failure to practice infection control standards related to EBP and hand hygiene has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 13 sampled residents (Resident #11, #14, #25, #90, and #139) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions, urinary catheters, and hand hygiene has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to ensure care and services were provided according to accepted standards of quality for 1 of 2 sampled residents (Resident #5) observed during stand-pivot transfers. Failure to ensure staff place call lights within the resident's reach placed residents at risk for falls and/or injury.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the resident or the resident's representative a written notice of transfer for 1 of 3 residents (Resident #8) reviewed for hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the resident or the resident's representative a written notice of bed hold for 1 of 3 residents (Resident #8) reviewed for hospital transfer. Failure to provide a written copy of the bed hold notice does not allow the resident and/or their representative to make an informed decision regarding their rights.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plans to reflect the current status for 1 of 13 sampled residents (Resident #5) and 2 supplemental residents (Resident #7 and #30). Failure to review and revise the care plans limited staff's ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow professional standards of practice regarding physician's orders for 1 of 1 sampled resident (Resident #139) with a catheter. Failure to ensure physician's orders are clearly understood, correctly transcribed, and entered in a timely manner may result in a resident receiving an inappropriate medication, test, treatment, and/or other intervention.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 1 of 2 sampled residents (Resident #14) observed during stand-pivot transfers. Failure to utilize a gait-belt during stand-pivot transfers placed residents at risk for falls and/or injury.

Inspectors wroteBased on record review and staff interview, the facility failed to assess residents with a history of trauma and identify known triggers for 1 of 1 sampled resident (Resident #33) reviewed for Post-Traumatic Stress Disorder (PTSD). Failure to ensure staff assess residents with PTSD upon admission, identify known triggers, and provide appropriate person-centered treatment/services may result in re-traumatization.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure each resident's entire drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for 1 of 5 sampled residents (Resident #14) reviewed for unnecessary medications. Failure to complete an Abnormal Involuntary Movement Scale (AIMS) screening for any resident receiving an antipsychotic medication may result in the resident experiencing an adverse reaction to the medication such as tardive dyskinesia [an involuntary movement disorder].

Inspectors wroteBased on record review, review of facility policy, and resident and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 2 of 12 sampled residents (Resident #13 and #16). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to promote the healing of pressure ulcers for 1 of 1 sampled resident (Resident #35) and 1 of 1 closed record (Resident #38) identified with a pressure ulcer. Failure to routinely assess, monitor, and measure pressure ulcers may result in delayed healing of the pressure ulcer.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate assistance for 1 of 1 sampled resident (Resident #17) observed during a sit-to-stand mechanical lift transfer and failed to provide adequate assistive devices for 1 of 8 sampled resident (#33) and one supplemental resident (#30) requiring staff assistance to transport/transfer. Failure to properly use the lift and use proper assistive devices placed the residents at risk for accidents with/without injury.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 1 of 7 residents (Resident #10) observed during medication administration. Three medication errors occurred during staff administration of 37 medications, resulting in an 8% error rate. Failure to properly prepare and administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions.