Parkview Care and Rehabilitation Center, Inc

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 3/27/2025 and completed on 4/3/2025, the facility did not conduct a comprehensive resident assessment within 14 calendar days after admission and not less than once every 12 months. This was identified for one (Resident #123) of one residents reviewed for the Resident Assessment Task. Specifically, Resident #123's five-day Prospective Payment System (PPS) Minimum Data Set (MDS) assessment was not completed timely and in accordance with the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual. The finding is: The facility's policy and procedure titled Completion of the RAI (Resident Assessment Instrument) Process, last revised on 2/4/2025, documented that all assessments will be completed within the guidelines outlined in the RAI (Resident Assessment Instrument) Manual. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/27/2025 and completed on 4/3/2025, the facility did not ensure the comprehensive person-centered care plan for each resident was developed and implemented to meet the resident's medical, nursing, mental and psychosocial needs. This was identified for one (Resident #96) of five residents reviewed for Accidents. Specifically, the resident's care plan required the use of floor mats. On 3/27/2025, 3/28/2025, and 4/1/2025, Resident #96 was observed in bed with only one floor mat on the left side of the resident's bed. The finding is: The facility Floor Mat policy and procedure last updated in October 2024 documented that floor mats may be selected for use as deemed appropriate by the interdisciplinary team, and floor mats should only be on the floor when the resident is resting in bed. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 3/27/2025 and completed on 4/3/2025, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was identified for one (Resident #14) of four residents reviewed for Pressure Ulcers. Specifically, on multiple occasions, the weight setting on Resident #14's air mattress weight setting was not consistent with the resident's current weight as required by the physician's order. Additionally, during the wound care observation, the treatment nurse did not follow the physician's treatment order and left the resident's sacral wound uncovered after the topical cream was applied to the sacral wound. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/27/2025 and completed on 4/3/2025 the facility did not ensure that each resident received proper treatment and assistive devices to maintain hearing abilities. This was identified for one (Resident #96) of one resident reviewed for vision and hearing. Specifically, Resident #96 had a Physician's order for an Audiology consult dated 1/17/2025 and again on 3/18/2025 to evaluate the resident's hearing ability and for the functionality of the resident's hearing aids, which were brought in by the resident's family member, before the resident can start using the hearing aids. As of 4/3/2025, there was no documented evidence that an Audiology consult was completed for Resident #96. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey, initiated on 3/27/2025 and completed on 4/3/2025, the facility did not ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified for one (Resident #299) of six residents observed during the Medication Administration Task. Specifically, Resident #299 had a change in the Physician's order for Oxycodone (a narcotic pain reliever). The medication dosage for Oxycodone was changed on the blister-pack label with hand-written dosage instructions written by a Licensed Practical Nurse, and the instructions were not accurate. The finding is: A review of the facility's policies titled Medication Storage dated 2/20/2025; Ordering and Obtaining Medications dated 3/1/2025; [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 11/8/2023 and completed on 11/15/2023, the facility did not ensure that a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standard of quality care was developed within 48 hours of admission. This was identified for one (Resident #11) of three residents reviewed for pressure ulcers. Specifically, Resident #11 was admitted on [DATE] with multiple areas of skin impairment. A Baseline care plan was not developed within 48 hours for the skin impairment as required. The finding is: [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 11/08/2023 and completed on 11/15/2023, the facility did not implement a comprehensive person-centered care plan for each resident to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for 1) one (Resident #130) of one resident reviewed for Activities of Daily Living, and 2) one (Resident #439) of three residents reviewed for Communication. Specifically, 1) Resident #130, who had diagnosis of Diabetes, had a Physician's order to monitor the resident's blood glucose level and report the findings to the Physician if the blood glucose levels were less than 70 milligrams (ml)/Deciliter(dl) or greater than 300 ml/dl. In October 2023, on three occasions Resident #130's blood glucose level was greater than 300 ml/dl. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 11/8/2023 and completed on 11/15/2023, the facility did not ensure comprehensive care plans were reviewed and revised to meet each resident's current needs. This was identified for one (Resident #49) of six residents reviewed for Accidents. Specifically, Resident #49 required extensive assistance of one person for transfers as per the resident's nursing care instructions and Comprehensive Care Plan (CCP). Resident #49 had non-compliant behavior of transferring independently. The facility staff were aware of the resident's noncompliance; however, the CCP was not updated to reflect the identified behavior. The finding is: The facility's policy, titled Accident/Incident, reviewed and revised 8/2022, documented a plan of care will be updated or initiated by the interdisciplinary team. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 11/8/2023 and completed on 11/15/2023, the facility did not ensure that a Physician Response (action) documented on a monthly Medication Regimen Review (MRR) was carried out to address an irregularity identified by the Pharmacist. This was identified for one (Resident #52) of five residents reviewed for Unnecessary Medications. Specifically, a serum Valproic Acid (an anticonvulsant medication to treat Bipolar Disorder and migraine headaches) level was requested for Resident #52 by the Nurse Practitioner (NP) on 9/12/2023 in response to the Consultant Pharmacist's Recommendation dated 9/5/2023; however, no Physician's Order was documented in the resident's Electronic Medical Record (EMR) and the serum Valproic Acid level was never obtained. The finding is: [...]

Inspectors wroteBased on observations, interviews and records review during the Recertification Survey initiated on 11/8/2023 and completed on 11/15/2023 the facility did not ensure that all controlled drugs were appropriately stored. This was identified on one (West Unit) of two facility medication rooms. Specifically, on 11/9/2023 at 10:25 AM, a 1 milliliter (ml) vial of Lorazepam containing a small amount of solution was observed on the top shelf of the [NAME] Unit narcotic box. The vial was not refrigerated (as required per manufacturer's recommendation) or labeled with a resident's name. The finding is: The facility policy and procedure on Open Injectable Storage and Handling, dated 10/2022 documented that single dose vials of injectable medication that are opened shall be discarded in the sharps container or other disposal method that is safe from resident contact and retrieval. On 11/09/23 at 10: [...]

Inspectors wroteBased on observation, interview, and record review during the Recertification Survey and Abbreviated Survey (Complaint #NY00274572) completed on 11/19/2021, the facility did not ensure resident rights to be free from abuse for one (Resident #235) of two Residents reviewed for Abuse. Specifically, Resident #232 hit Resident #235 when Resident #232 was attempting to lower the television volume in Resident #235's room. Both residents had a verbal exchange and Resident #232 hit Resident #235. Subsequently, Resident #235 was transferred to the hospital and returned to the Nursing Home with a hematoma to the right abdomen and a lip laceration with 3 sutures. The finding is: The facility Abuse Prohibition and Prevention policy dated 4/13/2021 documented each resident shall be free from abuse. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey completed on 11/19/2021, the facility did not ensure that care was implemented according to each resident's care plan for one (Resident #37) of one resident reviewed for Hydration. Specifically, Resident #37 was observed receiving Intravenous (IV) fluid at a rate exceeding the rate indicated in the Physician's order. The finding is: The facility's policy titled Intravenous Therapy last reviewed on 8/2020 documented that the nurse will review the Physician's (MD) order when starting a peripheral IV line. Resident #37 was admitted with diagnoses including Hemiplegia, Cerebral Infarction and Gastro-Esophageal Reflux Disease (GERD). [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00281022) completed on 11/19/2021, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #233) of two residents reviewed for Hospitalization. Specifically, Resident #233 was admitted to the facility from the hospital with a diagnosis of Myasthenia Gravis. The Hospital records received by the facility indicated there were 4 pages listing discharge medications; however, only three pages were received by the facility in the discharge paperwork. The facility did not follow up with the hospital to obtain the missing paperwork to reconcile all medications. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey completed on 11/19/2021, the facility did not ensure a system of records and accounts of all controlled drugs were maintained and reconciled. This was identified for two (Resident #55 and Resident 119) of two residents reviewed during the Medication Storage task. Specifically, Resident #55 was administered Oxycodone (a narcotic medication) Immediate Release (IR) 5 milligrams (mg) and Resident #119 was administered Tramadol (a narcotic medication) 25 mg without accurate reconciliation on the Controlled Substance Records (Narcotic Sheets).