Parkside Post Acute and Rehabilitation

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled, Food Storage: Cold Foods and Labeling and Dating, the facility failed to ensure frozen food wrappers were intact and that food items were not expired. This deficient practice had the potential to cause cross contamination of unwrapped meat and foodborne illness affecting 135 of 142 residents receiving meals prepared in the kitchen.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Heating, Ventilation, and Air Conditioning (HVAC), (Packaged Terminal Air Conditioner (PTAC)): Clean Air Filters, the facility failed to maintain a clean, homelike environment by not ensuring that the PTAC unit filters were free of debris in 2 of 48 rooms (A9, A8 located in A Hall) and failed to ensure PTAC unit grills were free of debris in 1 of 48 rooms (A8 located in A Hall) . The deficient practice had the potential to affect resident comfort, air quality, and infection control.

Inspectors wroteBased on observations, staff interviews, record review and review of facility's policy titled, Water Temperature Policy, the facility failed to keep the residents free of accident hazards as evidenced by water temperatures above 110 degrees Fahrenheit (F) in 8 of 138 resident rooms (A2, A4, E31, E19, E16, E3, B10 and B12 located in A, B, and E Halls ) and in 1 of 3 showers (B Hall). The deficient practice had the potential to cause injury to residents residing in these rooms.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Infection Prevention and Control Program, the facility failed to maintain appropriate infection control practices by not using sterile procedure during tracheostomy care for one of 60 sampled residents (R) (R120), not storing respiratory equipment in an approved container for two of 60 sampled R's (R2 and R5), not protecting shared medical supplies from contamination during wound care for one of 60 sampled R's (R10), by storing personal items on clean linen carts, and by staff not adhering to contact precautions by entering a room with a sign for contact precautions without proper PPE (personal protective equipment). The deficient practices had the potential to contribute to the transmission of infectious organisms among residents, staff, and visitors.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled, Preadmission Screening and Annual Resident Review (PASARR) Policy, the facility failed to obtain a level II PASARR screening for one of 60 sampled residents (R) (R41). The deficient practice had the potential to prevent R41 of achieving the highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the facility policy titled, Administration of Medications, the facility failed to follow physician orders for two of 60 sampled residents (R). Specifically, the facility failed to follow physician orders related to colostomy care for R90 and administration of medications for R122. The deficient practice had the potential to compromise the residents' health and safety.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of facility policies titled Urinary Catheter Care, Anchoring and Changing, the facility failed to provide proper catheter care and positioning for one of 16 residents (R) (R71). Specifically, staff failed to provide correct cleaning and failed to ensure the catheter drainage bag was properly positioned. The deficient practice had the potential to cause pain, trauma to the urethra, catheter-associated urinary tract infections (CAUTIs), and impaired drainage.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled, Oxygen Therapy Policy, the facility failed to obtain a physician's order for oxygen (O2) for one of 12 residents (R) (R165) and failed to ensure that O2 was administered as ordered for one of 12 Rs (R120) who use O2. This deficient practice had the potential to cause respiratory complications and inadequate oxygenation.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled, Storage of Medications and Biologicals and Administration of Medications, the facility failed to ensure the secure storage of medications by not locking medication carts when unattended for one of six medication carts. The deficient practice had the potential to allow residents, unauthorized staff, or visitors to access medications and biologicals, or to tamper with items stored on the cart.

Inspectors wroteBased on record review, resident and staff interviews, and review of the facility policy titled, Administration of Medications, the facility failed to document medication administration for 2 of 60 sampled residents (R) (R122 and R102. This deficient practice created an inaccurate record of care and services provided to the residents which had the potential to affect continuity of care.

Inspectors wroteBased on record review, interviews, and review of policies titled Notification of Resident's Change in Condition, and Laboratory Testing, the facility failed to notify the physician and responsible party (RP) for a change in condition for one of 44 sampled residents (R) (R660). Specifically, facility staff failed to report critical urinalysis lab results for R660, who experienced actual harm on 12/16/2023, resulting in the resident being hospitalized for 11 days with urosepsis (sepsis caused by urinary tract infection) and acute renal failure.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide appropriate treatment and care for one resident (R) (R660) with a severe urinary tract infection (UTI). Abnormal urinalysis (UA) and culture and sensitivity (C&S) results were reported to the facility on [DATE] and the facility failed to seek medication for treatment. Actual Harm occurred on 12/16/2023 when R660 was admitted to the hospital for 11 days with a urinary tract infection and acute renal failure. The sample size was 44.

Inspectors wroteBased on observations, record review, staff interview, and review of the policies titled Care Plan Policy and Smoking Policy for Residents, the facility failed to develop a care plan for three of 44 sampled residents (R) R108 for Post-Traumatic Stress Disorder (PTSD), R116 for dementia, and R126 for smoking.

Inspectors wroteBased on observations, record review, interviews, and review of the facility's Holiday Newsletter, policy titled Cleaning and Disinfecting Residents' Rooms, and the Material Safety Data Sheet (MSDS) for Rapid Multi Surface Disinfectant Cleaner, the facility failed to ensure the environment was free from potential accident hazards. Specifically, R2 had an electrical power strip lying in the bed with her, providing electrical to multiple devices. In addition, the facility failed to ensure a chemical spray bottle with cleaning solution was properly stored while not in use placing R82 at risk for exposure to the chemical. The sample size was 44.

Inspectors wroteBased on observations, record review, interviews, review of the Centers for Disease Control and Prevention (CDC) guidelines and facility policies titled, Hand Washing/Hand Hygiene Policy and, Perineal (Skin) Care for Incontinent Resident, the facility failed to implement an effective Infection Control Program to prevent the development and transmission of communicable diseases and infection. Specifically, the nursing staff failed to offer and/or encourage hand hygiene for residents during meal delivery by four of four staff members observed delivering meals; housekeeping staff failed to perform hand hygiene between resident rooms and between glove changes on one of five halls (A Hall); and nursing staff failed to change gloves and perform hand hygiene when going from dirty to clean during incontinent care for one of two sampled residents (R#90) reviewed for incontinent care. [...]

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Notification of Resident's Change in Condition, the facility failed to ensure the physician was immediately notified when resident (R) R#32, complained of pain following a fall for one of three residents reviewed for falls.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure showers were regularly provided as scheduled and facial hair was removed when needed for one resident (R) #58 of three sampled residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observations, record review, interviews, and review of facility policies, the facility failed to ensure causative factors for falls were investigated and documented, interventions were developed and implemented to address the causative factors, and care planned interventions to prevent falls were consistently implemented for one resident (R) R#46, of three sampled residents reviewed for falls.

Inspectors wroteBased on record review, staff interviews, and review of the facility policies titled, Physician Order Review Process and Medication and Treatment Orders, the facility failed to ensure a psychiatric consultation was provided in accordance with the physician's order for one resident (R) R#7, of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, record review, staff interviews, and review of a facility policy titled, Controlled Substances, the facility failed to ensure controlled substances were accurately documented on a destruction form for 4 of 59 controlled substances reviewed.

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled, Pharmacy Services Overview, the facility failed to follow the consultant pharmacist's recommendations related to an as-needed (PRN) antianxiety medication order for one of five resident's (R) R#7, reviewed for unnecessary medications.

Inspectors wroteBased on record review, interviews, and review of facility policies, the facility failed to ensure psychotropic medications including antipsychotic and antianxiety medications were not ordered as needed (PRN) beyond 14 days, failed to document the rationale in the resident's medical record and indicate the duration for the PRN order for two of five sampled residents (R) R#102 and R#7; and failed to provide consistent documentation of target behaviors and potential side effects of psychotropic medications for two of five sampled residents (R) R#102 and R#7, reviewed for unnecessary medications.

Inspectors wroteBased on observations, staff interviews, and review of a facility policy, the facility failed to ensure medication carts were locked when not attended for one of six medication carts. The census was 153.