Parkview Care Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infections in three of four hallways. Specifically, the facility failed to:-Ensure staff donned (put on) the appropriate personal protective equipment (PPE) for a resident requiring enhanced barrier precautions (EBP) during wound care for Resident #10;-Ensure housekeeping staff cleaned the residents' toilets in a sanitary manner;-Ensure sterility was maintained during tracheostomy care and suctioning for Resident #66; and,-Ensure staff performed hand hygiene while providing meal assistance.

Inspectors wroteBased on observations and interviews the facility failed to ensure all drugs and biologics used in the facility were properly stored and labeled for one of four medication carts and one of one medication rooms reviewed for storage and labeling. Specifically, the facility failed to ensure prescription medications were discarded after the expiration date and after they were discontinued.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value and was palatable in taste, texture and temperature. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and temperature.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure three (#66, #30 and #7) of five residents out of 45 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to:-Ensure professional standards were used when nursing staff completed oral and tracheostomy suctioning for Resident #66;-Ensure Resident #30's head of his bed was elevated 30 to 45 degrees while administering a water flush through his gastrostomy tube (a small device inserted through the abdomen directly into the stomach); and,-Create and implement a comprehensive care plan for Resident #7's insomnia or his use of Trazodone (antidepressant with off label use of sleep aid), and failed to follow Resident #7's physician's orders to track his hours of sleep.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#7) of five residents reviewed for accident hazards out of 45 sample residents. Specifically, the facility failed to prevent a second-degree burn from food for Resident #7.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%). Specifically, the facility's medication error rate was 7.69%, or two errors out of 26 opportunities.

Inspectors wroteFindings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 1/27/26 to 1/28/26, resulting in the deficiency being cited as past noncompliance, with a correction date of 12/25/25. I. Facility plan of corrective actionMeasure to address systemic concernsThe facility provided immediate staff education to all nursing staff to:-Document all resident monitoring activities when the resident was on a one to one or line of sight supervision;-Cover units to provide supervision for resident to ensure health and safety of the residents in need, when staff are on break;-Be knowledgeable on identifying types of abuse, reporting requirements and timelines for reporting allegations of abuse; [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in one of one nourishment room and the main kitchen. Specifically, the facility failed to: -Ensure food was labeled and dated and disposed of timely in the nourishment room freezer, main dining room refrigerator/freezer, and kitchen dry storage area; -Ensure food was properly cooled; -Ensure artificial fingernails with polish were not worn by a food worker; -Ensure appropriate hand washing occurred in the main kitchen; -Ensure dishes were dried appropriately; -Ensure the nourishment room freezer was monitored to ensure it was at the correct temperature; and, -Ensure towels were stored properly.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of one medication refrigerator, one of two treatment carts and one of four medication carts. Specifically, the facility failed to: -Ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator; -Ensure medications were not left on top of the medication cart when unattended; and, -Ensure the treatment cart was locked when left unattended.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure proper hand hygiene was conducted during medication administration; -Follow infection control practices during enteral nutrition administration (feeding through a tube placed in the stomach or small intestine); and, -Follow infection control practices during tracheostomy care.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure for five (#21, #22, #2, #36 and #30) of six residents reviewed were provided with services or treatments to prevent the reduction in range of motion, out of 35 sample residents. Specifically, the facility failed to ensure Residents #21, #22, #2, #36 and #30 were provided preventative measures to help minimize the worsening of contractures.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide resident care in a dignified and respectful manner for two (#53 and #36) of three residents reviewed for dignity out of 35 sample residents. Specifically, the facility failed to ensure two residents (#53 and #36) were provided with clothes to wear. Both residents daily wore hospital gowns in their rooms as well as in other areas in the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of the resident needs and preferences for two (#53 and #36) of four residents reviewed for reasonable accommodations out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #53 a dependent resident could watch his television in his room. His television was positioned behind his bed where he was unable to see it; and, -Ensure Resident #36 was provided a wheelchair so that she could get out of her bed. She had been bed bound daily for about six weeks.

Inspectors wroteBased on record review and interviews, the facility failed to report an alleged violation of abuse to the State Survey and Certification Agency for one (#2) out of one resident reviewed for abuse out of 35 sample residents. Specifically, the facility's director of nursing (DON) knew of a resident's allegation of a staff member's verbal and physical abuse. The facility failed to report the resident's alleged violation to the State Survey Agency. Cross-reference F610, Failure to investigate/prevent/correct alleged violation.

Inspectors wroteBased on record review and interviews, the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (#2) of one resident reviewed for investigations out of 35 sample residents. Specifically, the facility failed to investigate a resident's allegation of verbal abuse that a staff member called her a bad word in Spanish. The facility failed to investigate the resident's allegation of physical abuse that a staff member pulled her hair. The facility began their investigation on 11/17/22, during the survey, although the allegation had happened on 8/17/22. Cross-reference F609, Failure to report alleged violation.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for two (#30 and #36) of three sample residents out of 35 sample residents. Specifically, the facility failed to ensure that Resident #30 and #36, who were at risk for skin breakdown, were repositioned timely.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental, and psychosocial well-being were provided for one (#22) of two residents reviewed for activities out of 35 sample residents. Specifically, the facility failed to ensure Resident #22 was invited to group activities, which was her preference, and developed a comprehensive care plan which addressed the resident's socialization and activity needs.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure for one (#4) of three residents reviewed received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being, out of 35 sample residents. Specifically, the facility failed to provide a plan of care specific and personalized to the resident to address an unexpected 8.65% (percent) weight loss in six months.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure two (#265 and #30) of three out of 35 sample residents who required respiratory care were provided such care consistent with professional standards of practice. Specifically, the facility failed to: -Ensure a sterile technique was used within accepted standards of practice for tracheostomy care suctioning for Resident #265 and #30; and, -Ensure physician's orders were followed for Resident #265's tracheostomy care.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#10) of nine residents reviewed for medication errors of 35 sample residents. Specifically, the facility failed to ensure that Resident #10 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration.