Parkview Care Center

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure comprehensive care plans included a discharge plan of care. This affected four (#13, #31, #32, and #33) of five residents reviewed for discharge care plans. The facility census was 29.

Inspectors wroteBased on medical record review, observation, staff interview, facility policy review, and manufacturer user manual, the facility failed to ensure pressure relieving interventions were implemented to promote healing and prevent the development of pressure ulcers. Actual Harm occurred when Resident #02 was placed on a faulty alternating air mattress without standard wound or equipment assessment which resulted in the deterioration of an existing stage IV pressure ulcer (full-thickness loss with exposed bone/muscle/tendon) and the development of three in-house acquired unstageable (obscured by sloth/eschar) deep tissue injuries (purple/maroon discoloration, intact or blistered skin) to the back and buttock. This affected one (#02) of four residents reviewed for pressure ulcers. The facility census was 31.

Inspectors wroteBased on employee personnel file review, review of the facility criminal background log, review of the facility daily timecard activity, staff interview, and policy review, the facility failed to ensure nursing staff with disqualifying legal convictions were not employed by the facility. This affected all 31 residents residing in the facility.

Inspectors wroteBased on observation, staff interview, review of the control substance inventory sheet, and policy review, the facility failed to ensure controlled substances and narcotic medications were correctly handled, and inventoried. This affected eight (#07, #15, #06, #16, #23, #22, #09 and #21) of eight residents identified by the facility who received narcotic medications. In addition, the facility failed to ensure narcotic medications were reconciled at the point of administration. This affected one (#07) of eight residents who received narcotic medication. The facility census was 31.

Inspectors wroteBased on medical record review, observation, and staff and resident interview, the facility failed to ensure interventions to manage lower extremity edema were implemented in accordance with physician orders. This affected two (#05 and #06) of six residents reviewed for physician prescribed treatment applications. The facility census was 31.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident's representative was notified of changes in condition. This affected one (#31) of three residents reviewed for changes in condition. The facility census was 30.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure resident weights were obtained per physician orders and failed to ensure monitoring of nutritional interventions. This affected one (#31) of three residents reviewed for nutrition. The facility census was 30.

Inspectors wroteBased on observations, staff interview, and review of a job description, the facility failed to ensure resident rooms were maintained in a safe and sanitary condition. This affected three (#31, #3 and #30) of six resident rooms observed during the survey. The facility census was 30.

Inspectors wroteBased on medical record review, review of hospital records, staff interview, and review of facility policy, the facility failed to ensure physician orders were in place and care was provided for a peripherally inserted central catheter (PICC line - used for long term intravenous [IV] access). This affected one (#5) of one resident reviewed for PICC line care. The facility identified one resident with a PICC line. The facility census was 36.

Inspectors wroteBased on medical record review, review of hospital records, staff interview, and review of the facility policy, the facility failed to ensure qualified staff were available to administer medication through a Peripherally Inserted Central Catheter (PICC) line. This affected one (#5) of one resident reviewed for intravenous (IV) medication administration. The facility identified one resident who receive IV medications. The facility census was 36.

Inspectors wroteBased on review of the medical record, review of Minimum Data Set (MDS) admission assessments, staff interview, and policy review, the facility failed to ensure an admission MDS skin condition assessment was accurate. This affected one (#2) of three residents reviewed for MDS admission assessments. The facility census was 36.

Inspectors wroteBased on review of the medical record, resident interview, staff interview, and policy review, the facility failed to ensure colostomy drainage bag changes were completed per physician orders. This affected one (#2) of two residents reviewed for ostomy care. The facility identified two residents with colostomies. The facility census was 36.

Inspectors wroteBased on review of the medical record, review of available facility medications, staff interview, and policy review, the facility failed to ensure a resident was free from a significant medication error. This affected one (#2) of three residents reviewed for medications. The facility census was 36.

Inspectors wroteBased on closed medical record review, staff interviews, Emergency Medical Services (EMS) staff interview, Coroner investigator interview, review of an EMS run report, review of hospital and emergency room (ER) documentation, review of an electronic mail (e-mail) document, review of a Coroner's report and Coroner's Report of Death document, and review of facility policies, the facility failed to ensure a resident (#50), with known swallowing issues, was provided with appropriate and timely treatment and services when the resident was assessed with changes in condition. [...]

Inspectors wroteBased on review of a the facility water management plan, staff interview, review of the Centers for Disease Control and Prevention (CDC) website, and policy review, the facility failed to implement a complete water management program to prevent the growth of Legionella bacteria and failed to wear gloves during administration of an injected medication. This had the potential to affect all 34 residents residing in the facility. The census was 34.

Inspectors wroteBased on medical record review, resident and staff interview, review of activities calendars, and policy review, the facility failed to provide activities of resident preference on evenings and weekends to support the physical, mental, and psychosocial well-being of the resident. This affected one (#18) of one residents reviewed for activities. The facility census was 34.

Inspectors wroteBased on observation, and staff interview the facility failed to maintain medical equipment and supplies in a sanitary manner. This affected all 34 residents residing in the facility.

Inspectors wroteBased on observation, and staff interview the facility failed to ensure resident heating and air conditioning equipment was operational inside resident rooms. This affected one (Resident #2) of four residents reviewed for environmental heating, ventilation and cooling in the facility. The total facility was census of 34.

Inspectors wroteBased on observation, and staff interview the facility failed to ensure the physical environment was maintained free of damage or hazardous conditions. This affected one (Resident #1) of four residents rooms observed for environmental conditions in the facility. The total facility census was 34.

Inspectors wroteBased on observation, review of medical records, review of self-reported incidents (SRI), review of witness statements, interviews with staff, residents, and family, and policy review, the facility failed to ensure one cognitively impaired resident (#03) was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for serious physical, mental and/or psychosocial negative outcomes for two residents (#03 and #21) when the facility failed to recognize and respond to Resident #02's increased sexual behavior. State Tested Nursing Assistant (STNA) #112 reported on 04/20/24, Resident #02 had pulled his genitalia out in front of Resident #03. STNA #112 reported the incident to a nurse. On 04/26/24, Resident #02 was found with Resident #21 with his pants unfastened and was putting away his genitalia. [...]

Inspectors wroteBased of review of quarterly Quality Assessment and Assurance (QAA) meeting sign in sheets, interview, and policy review, the facility failed to ensure quarterly QAA meetings were completed as required. This had the potential to affect all residents. The facility census was 28.

Inspectors wroteBased on review of the medical record, review of nurse practitioner progress notes and physician progress notes, interview, and policy review, the facility failed to ensure the physician and nurse practitioner were alternating resident visits. This affected five (#17, #19, #03, #02, #11) of six residents reviewed for physician visits. The facility census was 28.

Inspectors wroteBased on review of Self-Reported Incidents (SRIs), review of the medical record, interview, and policy review, the facility failed to report allegations of sexual abuse. This affected three (Residents #21, #02, #03) of four residents reviewed for abuse. The facility census was 28.

Inspectors wroteBased on review of the medical record, observation, interview, and policy review, the facility failed to ensure nutritional supplements were provided per physician orders. This affected two (#25, #19) of three residents reviewed for nutrition. The facility census was 28.

Inspectors wroteBased on review of the medical record, staff interview, and review of facility policies, the facility failed to ensure a physician was notified when the facility was unable to administer a resident's enteral nutrition as ordered. This affected one (#38) of two residents reviewed for tube feeding. The facility census was 28.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident received enteral feedings per physician orders. This affected one (#38) of two residents reviewed for tube feedings. The facility census was 28.

Inspectors wroteBased on review of the medical record, review of Self-Reported Incidents (SRI), agency staff interview, staff interview, and policy review, the facility failed to ensure a resident's narcotic medication was not misappropriated. This affected one (#25) of one resident reviewed for misappropriation. The facility census is 28.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the ability to affect all 30 residents who received food from the kitchen. The facility census was 30.

Inspectors wroteBased on medical record review, observation, and staff interviews, the facility failed to provide timely dental services for a resident. This affected one (Resident #12) of three residents reviewed for dental services. The facility census was 33.

Inspectors wroteBased on observation, staff interviews, and review of policy, the facility failed to ensure a safe, comfortable, homelike environment by not ensuring the floors were maintained; showers were free from disrepair and discolored grout. This affected all 31 residents in the facility. The facility census was 31.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure medical records contained accurate and identifiable entries by specified nursing staff. This affected four (#23, #6, #10 and #5) of four medical records reviewed for accuracy and had the potential to affect all 27 residents residing in the facility. The facility census was 27.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure multiple use medication vials were stored and maintained to promote effectiveness. This affected one (#9) resident receiving insulin and a undetermined number of residents regarding tuberculosis testing in a facility census of 27.

Inspectors wroteBased on observation, staff interview, and review of policy, the facility failed to distribute meals to residents in a safe and sanitary manner. This affected 15 (#4, #5, #9, #10, #11, #13, #14, #16, #19, #20, #22, #24, #25, #26, and #78) of 15 residents who received meal trays in their rooms. The facility census was 27.

Inspectors wroteBased on record review, staff interview, and review of the facility's documents, the facility failed to allow residents to smoke. This affected one (#4) of three residents reviewed for smoking. The facility census was 27.

Inspectors wroteBased on observation, medical record review, and resident and staff interview, the facility failed to ensure nail care and bathing was provided timely to a resident who required assistance from staff with activities of daily living. This affected one (Resident #11) of 16 residents observed for activities of daily living. The facility identified 19 residents who required assistance from staff with bathing and 20 residents who required assistance from staff with dressing. The facility census was 27.

Inspectors wroteBased on observation, medical record review, review of the facility's skin assessment policy, and resident and staff interview, the facility failed to ensure a resident's skin was monitored routinely and the resident's skin impairments were reported to the nurse and physician timely. This affected one (Resident #11) of one residents reviewed for non-pressure related skin issues. The facility identified one resident with a rash related skin issue. The facility census was 27.

Inspectors wroteBased on medical record review, staff interview, and review of the facility's policy, the facility failed to ensure treatments were completed per physician order. This affected one (#5) of one resident reviewed for pressure ulcers. The facility identified three current residents with pressure ulcers residing in the facility. The facility census was 27. Findings Include: Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia, bipolar disorder, anxiety, depression, psychotic disorder, hallucinations, irritability and anger, muscle weakness, pressure ulcer of left heel, pressure-induced deep tissue damage of right and left heels, non-pressure chronic ulcer of lower left and right legs, edema, chronic pain, and type II diabetes mellitus. [...]

Inspectors wroteBased on observation, medical record review, and resident and staff interview, the facility failed to ensure residents who required supervision were monitored during smoking. This affected one (Resident #10) of seven residents identified by the facility who required supervision while smoking. The facility census was 27.

Inspectors wroteBased on observations, medical record review, staff interviews, and review of the facility's policy, the facility failed to ensure Resident #23 received appropriate treatment regarding the maintenance of a suprapubic indwelling urinary catheter and failed to ensure Resident #78 was provided with specific interventions to maintain urinary and bowel continence. This affected two of two residents (#23 and #78) reviewed for catheter care and incontinence care. The facility identified two residents with an indwelling or external catheter. The facility identified two residents on a urinary toileting program and three residents on bowel toileting program. The facility census was 27.

Inspectors wroteBased on record reviews, staff interview, and policy review, the facility failed to ensure pharmaceutical recommendations were reviewed by the physician. This affected three (#5, #6, and #10) of five residents reviewed for unnecessary medications. The facility census was 27.

Inspectors wroteBased on medical record review, family and staff interview, and review of policy, the facility failed to ensure resident food preferences were identified and subsequently honored. This affected one (#22) of two residents reviewed for food preferences. The facility census was 27.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the daily posted nursing staff information was updated timely as required. This had the potential to affect all 27 residents residing in the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the assessment used to determine what resources were necessary to care for the residents competently during both day-to-day operations and emergencies was updated accurately. This had the potential to affect all 27 of 27 residents residing in the facility.

Inspectors wroteBased on observation, review of a manufacture's instructions, review of the infection control surveillance log, staff interview and policy review, the facility failed to ensure glucometers were properly sanitized/disinfect prior to use on resident's. This had the potential to affect five residents (#1, #5, #8, #9, #25) who had orders for blood sugar monitoring on the C and D halls. Additionally, the facility failed to establish and implement an infection control program to ensure ongoing surveillance of infections to to prevent the spread of infections and ensure appropriate treatment of infections. This had the potential to affect all 29 residents. The facility census was 29.

Inspectors wroteBased on review of the infection control surveillance log, staff interview and policy review the facility failed to implement an antibiotic stewardship program to prevent the spread and ensure appropriate treatment of infections. This had the potential to affect all 29 residents. The facility census was 29.

Inspectors wroteBased on medical record review, review of the facility activities calendars and staff and resident interview, the facility failed to provide scheduled group activities for the residents. This affected one (#16) out of two residents reviewed for activities and had the potential to affect 14 additional residents (#12, #127, #8, #17, #130, #2, #3, #4, #1, #25, #15, #14, #13, #9) identified by the facility who typically attended group activities. The facility census was 29.

Inspectors wroteBased on a record review and family and staff interviews, the facility failed to provide resident's responsible party statements of residents trust accounts. This affected one (#8) of 18 residents reviewed during the initial pool process of the annual survey. The facility census was 29.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure a resident was free from unnecessary medication when staff failed to monitor a resident's blood pressure and/or pulse rate prior to administering medications with physician ordered parameters. This affected one (#2) of five residents reviewed for unnecessary medications during the annual survey. The facility census was 29.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure laboratory testing was completed per physician orders. This affected one (#24) of five residents reviewed for unnecessary medications during the annual survey. The facility census was 29.

Inspectors wroteBased on medical record review, review of the influenza (flu) shot log, staff interview and policy review, the facility failed to administer the appropriate influenza vaccination to Resident #122 and flailed to offer the appropriate pneumococcal vaccinations to Resident #8. This affected two (#8 and #122) of five residents reviewed for immunizations. The facility census was 29.