Parkview Care Center

Inspectors wroteBased on observation, interview and document review, the facility failed to provide physical therapy and occupational therapy as ordered for 5 of 5 residents (R2, R8, R13, R25, R26) reviewed for rehabilitation and restorative services.

Inspectors wroteThe facility failed to maintain complete and accurate accounting records of resident personal funds for 10 of 10 residents (R17, R18, R19, R20, R21, R22, R23, R12, R9, R11) whose funds were maintained in a commingled facility trust account.

Inspectors wroteBased on interview and document review the facility failed to notify the physician of recurrent refusals of physician ordered medication for 1 of 1 residents (R21) who required lactulose for treatment and management of constipation and hepatic failure/alcoholic cirrhosis.

Inspectors wroteBased on observation, interview, and document review the facility failed to revise behavioral care plan after resident-to-resident altercation for 1 of 1 resident (R11) reviewed for abuse. In addition, the facility failed to revise the care plan to reflect ongoing pattern of medication refusals for 1 of 1 resident (R21) who was prescribed a clinically significant medication used to treat a diagnosis of cirrhosis/hepatic failure.

Inspectors wroteBased on observation, interview, and record review the facility failed ensure comprehensive assessments for appropriate sling sizes for full body mechanical lift according to manufacturer guidelines to ensure safe transfers to mitigate the risk of injury for 2 of 2 residents (R16, R10) reviewed for safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess, monitor, timely develop and revise a care plan, and follow physician-ordered treatments for a surgical wound for 1 of 3 residents (R1) reviewed for non-pressure related skin injuries. The facility's failures resulted in actual harm, as evidenced by documented deterioration of R1's surgical wound from partial to complete dehiscence, with measurable increases in wound depth and tunneling, increased pain, and the need for ongoing treatments.

Inspectors wroteBased on observation, interview, and document review the facility failed to monitor, comprehensively assess, develop, and implement individualized interventions to prevent/mitigate the risk of pressure ulcers to /or deterioration for 2 of 3 residents (R2, R3) reviewed for pressure ulcers. This resulted in actual harm for R2 who developed an unstageable pressure ulcer on her right heel and stage 3 pressure ulcer on sacrum.

Inspectors wroteBased on observation, interview, and document review the facility failed to revise the care plan for 2 of 3 residents (R1, R2) who were reviewed for non-pressure skin concerns and pressure ulcers.

Inspectors wroteBased on observations, interviews, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 1 of 3 residents (R4) observed for handwashing/hand hygiene during wound care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure plates, trays, and plate covers were completely dry before storing, and failed to ensure refrigerated food was disposed of timely to prevent bacterial growth and foodborne illness. This had the potential to affect all 18 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to report the potential theft of money to the State Agency (SA) for 1 of 1 resident (R6) reviewed for personal property.

Inspectors wroteBased on interview and document review, the facility failed to investigate the potential theft of money for 1 of 1 resident (R6) reviewed for personal property.

Inspectors wroteBased on interview and document review, the facility failed to accurately code antipsychotic medication use on Section N of the Minimum Data Set (MDS) for 1 of 5 residents (R16) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a fan blowing directly on clean dishes was free of dust and debris. This had the potential to affect all 18 residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess, monitor, and provide interventions to prevent pressure ulcer development, promote healing, and prevent deterioration for 1 of 3 residents (R3) who had pressure ulcers. The facility's failures resulted in harm when R3 developed a stage 2 pressure ulcer (PU) that deteriorated to a stage 3.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess and monitor for change in condition following computer tomography with contrast dye to ensure appropriate and prompt treatment for 1 of 1 residents (R1) who was at risk for acute renal failure. Additionally based on observation, interview, and record review the facility failed to comprehensively assess, monitor, and treat wounds for 1 of 1 residents (R2) reviewed for non-pressure skin concerns.

Inspectors wroteBased on interview and document review, the facility failed to ensure provider ordered medications were administered timely for 1 of 1 resident (R1).

Inspectors wroteBased on observation, interview, and document review the facility failed to follow the appropriate food preparation safety requirements for thawing frozen meat to reduce and/or prevent the risk of food borne illness. This had the potential to affected 25 of 25 residents who obtained their meals from the kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to perform hand hygiene during cares, clean lift equipment after use, ensure 1 of 1 staff were fit-tested with N95 masks prior to entering COVID positive resident room, and adhere to EBP (enhanced barrier precautions) for 1 of 1 residents (R2). This had the potential to impact 25 residents residing in the facility.

Inspectors wroteBased on observation and interview and record review, the facility failed to clean resident rooms for (R80, R22, R24, R26, R18) who were on transmission-based precautions (TBP) timely and maintain an environment in good repair affecting 12 residents who used the west unit tub room.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (oral care and bathing) was provided for 2 of 2 residents (R26, R80) reviewed for activities of daily living (ADLs) who were dependent on staff for their care.

Inspectors wroteBased on interview and document review, the facility failed to implement the bowel movement (BM) protocol for 1 of 1 resident (R8) reviewed for constipation.