Parkview Health and Rehabilitation Center

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for 43 residents who reside in the facility and receive their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in a sanitary condition for 43 residents who reside in the facility and received meals from the facility's kitchen. This deficient practice placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 44 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility's (QAA) Quality Assessment and Assurance program failed to provide good faith efforts to identify multiple issues of concern for 33 residents residing in the facility.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to meet the professional standard of quality when preparing medications for administration to the residents. This placed the residents at risk of receiving the incorrect medications.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards when staff failed to place R24's motion detector floor alarm on when R24 was in his room. The facility failed to keep chemicals in the laundry room and the west supply room locked and inaccessible to the residents. This placed R24 at risk for a fall and all the residents at risk for residents at risk for accessing hazardous chemicals.

Inspectors wroteThe facility had a census of 44 residents. Based on observation, interview, and record review the facility failed to dispose of expired medications in a timely manner. This deficient practice placed residents at risk to receive ineffective medication.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents, with five residents reviewed for immunizations: Resident (R) 6, R13, R15, R19, and R22, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, obtain an informed declination or a physician documented contraindication for the pneumococcal vaccination, including the PVC 20 per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to promote care in a manner to maintain and enhance dignity and respect when staff administered an injection to Resident (R) 5 in the dining room, in view of residents and visitors, and failed to place a privacy bag on R2's urinary drainage bag. This placed the residents of the facility at risk for impaired dignity.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents. Based on record review and interview, the facility failed to provide Resident (R) 28, or their representative, the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055 and failed to provide R53 and R54 the completed Notice of Medicare Non-Coverage Form (NOMNC) Centers for Medicare and Medicare Services (CMS) form 10123, and the 10055 form. This placed the residents, or their representatives, at risk of making uninformed decisions about their skilled services and at risk of incurring charges if exercising their right to appeal.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents, with one reviewed for restraints. Based on observation, record review, and interview, the facility failed to provide a physician's order and assessment for a Lap Buddy (a cushioned pad that fits across the resident lap, placed in a wheelchair to remind residents to remain seated and to alert caregivers when a resident attempts to rise and prevents falls by discouraging independent movement) used to restrain Resident (R) 29 while in his wheelchair, placing the resident at risk for complications related to physical restraints.

Inspectors wroteThe facility had a census of 44 residents. Based on observation, record review and interview the facility failed to provide a background check for Housekeeping Supervisor (HS) U, who had been employed with the facility since 1979, left, and came back in 1991. This placed the residents at risk for abuse.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents. Based on record review and interview, the facility staff failed to identify an unwitnessed fall which resulted in serious injury as a potential allegation of neglect or abuse and report immediately to the State Survey Agency (SA), when Resident (R) 2, a cognitively impaired resident, had an unwitnessed fall with a fracture, and R8, a cognitively impaired resident, had a bruise of unknown origin. This placed the resident at risk for further injury and unidentified abuse or neglect.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide a Bed Hold Notification for Resident (R) 7 and R52 and notify the Office of the Long-Term Care Ombudsman (LTCO public official who works to resolve resident issues in nursing facilities) of the discharge for R7, R52, and R50 discharge from the facility. This placed the residents, and/or their representatives, at risk for uninformed care choices and impairs rights.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to revise the care plan to include Resident (R) 21's ongoing use of prophylactic (preventative in nature) antibiotics (class of medication to treat infections) related to a history of urinary tract infections (UTI- an infection in any part of the urinary system). This placed the residents at risk for physical decline, other related complications, and at risk for unnecessary medications.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 21's long-term use of prophylactic (preventative in nature) antibiotic (medications used to treat infections). This placed R21 at risk for inappropriate use of medications.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure the need for continued antibiotic (a class of medications used to treat infections) use for Resident (R) 21, which placed the resident at risk of receiving unnecessary medication.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents, with one reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R) 3, who was admitted to hospice on 06/19/25, which included a plan of care and a description of the services provided, which included contact information, visit frequency, medications, and medical equipment. This placed the resident at risk of not receiving needed care.

Inspectors wroteThe facility had a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to maintain a Quality Assessment and Assurance Committee (QA&A) that had the required membership in attendance. This placed the resident with a lack of quality care.

Inspectors wroteThe facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure the daily staff nursing hours were posted for one day of the onsite survey.

Inspectors wroteThe facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full time certified dietary manager for the 49 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to meet the nutritional needs of residents in accordance with established national guidelines, placing the residents at risk for unmet nutritional needs.

Inspectors wroteThe facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to prepare food in accordance with professional standards for food service safety when staff failed to check temperatures of food items prior to serving, failed to ensure clean and sanitary refrigerators and food preparation areas, failed to check sanitation for the dishwasher, and failed to keep food items off the floor in the food storage room. This placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 50 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 50 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training and possessed the required certification in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections.

Inspectors wroteThe facility had a census of 50 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to label and store drugs and biological medications appropriately. This deficient practice placed the affatced residents at risk to receive ineffective or inappropriate medication.

Inspectors wroteThe facility had a census of 50 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor and appearance, when dietary staff failed to follow a recipe while preparing four residents' pureed diets. This placed the residents at risk for impaired nutrition.

Inspectors wroteThe facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review and interview the facility failed to provide ice water in a sanitary manner. The facility further failed to ensure appropriate infection control principles related to the use of an indwelling catheter (tube inserted directly in the bladder to drain urine) for Resident (R) 14. These deficient practices placed the residents at risk for infection.

Inspectors wroteThe facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to report Resident (R) 43's allegation of physical and verbal abuse to the State Agency (SA). This placed the resident at risk for unidentified and/or ongoing abuse.

Inspectors wroteThe facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to apply compression hose to Resident (R) 4, as ordered by the physician. This placed the resident at risk for ongoing complications related to edema (swelling resulting from an excessive accumulation of fluid in the body tissues).

Inspectors wroteThe facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide a safe environment for the three cognitively impaired independently mobile residents who resided on the [NAME] and the West/East halls. The facility further failed to ensure an environment free from accident hazards for Resident (R)2. This placed the affected resident at risk for injury.

Inspectors wroteThe facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to implement the Registered Dietician (RD) recommendation for Resident (R) 4's weight loss which placed R4 at risk for further weight loss. The facility further failed to monitor R14 and R43's physician ordered fluid restriction which placed R13 and R43 at risk of complication related to hydration status.

Inspectors wroteThe facility had a census of 50 residents. The sample included 13 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess the actual rail being used to assure safety for Resident (R)2. This placed the affected resident at risk for injury.

Inspectors wroteThe facility had a census of 50 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility's pharmacy services failed to provide medication in the specific dosage prescribed when they packaged the pills for the facility. This deficient practice placed Resident (R) 3 at risk for an incorrect dose of medication.

Inspectors wroteThe facility had a census of 50 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to prevent a significant medication error for Resident (R)3. This placed the resident at risk for adverse medication effects.

Inspectors wroteThe facility had a census of 52 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in a sanitary condition for 51 residents who resided in the facility and received meals from the facility kitchen, placing them at risk for food borne illness.

Inspectors wroteThe facility had a census of 52 residents. The sample included 13 residents with six reviewed for dignity. Based on observation, record review, and interview the facility staff failed to treat Resident (R) R12,R16, R32, R23 and with dignity when staff stood over the residents when assisting them to eat, and when staff curled R16, R35, R36, R23, and R32's hair at the dining room table during meal service and dining and when staff gave (R) 41 medicated ointment to put in his nose while he was seated at the dining table with other residents. This placed the residents at risk for an undignified dining experience.

Inspectors wroteThe facility had a census of 52 residents. The sample included 13 residents. Based on record review and interview the facility failed to provide five of five residents or their representatives a current Center of Disease Control (CDC) Vaccination Information Statement (VIS), dated 08/06/21, when staff obtained consent for the Influenza vaccination administered on 09/29/21 and 10/01/21. This deficient practice placed residents at risk to make uninformed decisions about their immunizations.

Inspectors wroteThe facility had a census of 52 residents. The sample included 13 residents with one reviewed for physical restraint (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) use. Based on observation, interview, and record review the facility failed to assess Resident (R) 23 for the use of physical restraints, failed to obtain consent from the resident or resident's representative, and periodically re-assess for the continued use. This deficient practice placed R23 at risk for unnecessary physical restraint.

Inspectors wroteThe facility had a census of 52 residents. The sample included 13 residents. Based on observations, record review, and interview, the facility failed to review and revise Resident (R) 3 plan of care with resident centered interventions aimed to prevent falls which placed the resident at increased risk of falls and injury. -R3's Physician Order Sheet (POS), dated 05/04/22, included diagnoses of low back pain, urinary tract infection, diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertensive (elevated blood pressure), heart disease, dizziness and giddiness, and repeated falls. The admission Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition, required limited assistance of one staff for transfers and walking, was not steady, and only able to stabilize with human assistance during transition and walking. [...]

Inspectors wroteThe facility had a census of 52 residents. The sample included 13 residents with five reviewed for accidents. Based on observation, record review and interview the facility failed to ensure Resident (R) 24's motion alarm was turned on at all times as directed in her plan of care and failed to identify causative factors and implement interventions on R3's care plan to prevent further falls. This placed the resident at increased risk for falls and fall related injury.

Inspectors wroteThe facility had a census of 52 residents. The sample included 13 residents with three reviewed for urinary catheter (tube inserted into the bladder to drain urine) or urinary tract infection (UTI). Based on observation, record review and interview, the facility staff failed to change gloves when providing Resident (R) 3 and R24 incontinent cares and continued to provide care with the same soiled gloves. This placed the residents at risk for infection.

Inspectors wroteThe facility had a census of 52 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to store oxygen cannula and tubing in sanitary condition for one of one resident reviewed for respiratory care, Resident (R) 42. This placed the resident at risk for respiratory infections.

Inspectors wroteThe facility had a census of 52 resident. The sample included 13 resident with eight reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the consultant pharmacist (CP) identified and reported inappropriate diagnoses for four of Resident (R) 12's physician ordered medications, and the facility failed to follow up with the CP recommendation for a stop date for R12's Lorazapam.

Inspectors wroteThe facility had a census of 52 residents. The sample included 13 residents with eight review for unnecessary medication. Based on observation, interview, and record review the facility failed to identify appropriate medication diagnoses for R12. This deficient practice placed R12 at risk for unecessary medication therapy.

Inspectors wroteThe facility had a census of 52 residents. The sample included 13 residents with eight reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to document appropriate indications for administration and failed to place a stop date on as needed (prn) psychotropic (medication used to treat mental health disorders) medication for Resident (R)12. This placed the resident at risk for unnecessary medications and related complications.

Inspectors wroteThe facility had a census of 52 residents. The sample included 13 residents. Based on observation, record review , and interview the facility failed to store drugs and biologicals for one of three medication carts placing the residents at risk for missing medications and unsafe access to medications.

Inspectors wroteThe facility had a census of 52 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to prepare pureed foods (a texture-modified diet in which all foods have a soft, pudding-like consistency) by methods that conserved nutritive value, flavor, and appearance for two residents who received pureed diets placing the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 52 residents. The sample included 13 residents. Based on observation, interview, and record review the facility failed to provide adequate infection control during wound care for Resident (R)34 when the nurse placed the unwrapped dressings and scissors directly on a visibly soiled bedside table and failed to clean the wound prior to applying the dressing. This deficient practice placed R34 at increased risk for a wound infection.