Parkview Health Care Facility

Inspectors wroteBasedonobservation interview and record review, thefacilityfailedensure the dignity of all residents was maintained at all times when stafffailedtoensure one resident's (Resident #23) catheter (a sterile tube inserted into the bladder to drain urine) bagwas coveredwithadignitybag when visible to others. A sample of 17 residents was reviewed in a facility with a census of 65. Reviewofthefacilityspolicytitled ResidentRights Rules andRegulations, updated10/01/21, showedthefollowinginformation -Residentshavetherighttobetreatedwithdignityandrespect -Residentshavetherighttoprivacyandrespectregardingaccommodations personalcare medicaltreatment writtenandtelephonecommunications andvisitswithotherindividuals 1. Reviewoftheresidentsfacesheet(brieflookatresidentinformation showedthefollowinginformation -admission date of 10/15/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care to all residents per standards of practice when staff failed to transcribe a physician order change in breathing treatments and failed to administer the breathing treatments as order for one resident (Resident #1). The facility census was 70. Review of facility policy, Physician Orders, reviewed November 2024, showed the following: -In most circumstances, orders should be entered electronically by the practitioner; -Verbal or telephone orders may be given to providers (for example, a nursing facility) only if there is an emergency situation when the electronic entry may delay care, or if computer access is not available to the practitioner; -Upon receipt of a written or faxed order, staff will scan the order into the resident's electronic medical records (EMR). [...]

Inspectors wroteBasedonobservation interview andrecordreview thefacilityfailedtoprovidepressure ulcer care consistent with standards of practice when the facility failed to consistently document regarding all wounds and failed to care plan regarding new wounds in a timely fashion for one oneresident (Resident#23) withe multiple pressure wounds. A sample of 17 residents was reviewed in a home with a census of 65. ReviewofthefacilityspolicytitledPressureUlcerWoundAssessmentandTreatment, lastrevisedon11/24, showedthefollowinginformation -Basicpreventionincludestoencouragehydration offermoisturizingcream provideincontinencecare repositioninbedorchart accordingtotheindividualpatientneeds caregoals tissuetolerance andresponsetotreatment avoidpositioningoncurrentpressureulcerwound. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible when staff continued to transfer one resident (Resident #14) with a lift that required resident participation after to two prior falls using the same lift and after the resident showed a decline in his/her ability to bear weight. A sample of 17 residents was reviewed in a facility with a census of 65. Review of the facility's policy titled Resident Handling, revised on 04/22, showed the following information: -Mobility and transfer decision flow chart is utilized when selecting appropriate assistive equipment and devices during assessment of resident capabilities for care planning and prior to patient handling activity. When indicated on the patient care plan, the required assistive devices may be varied according to the decision flow chart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care per standard of practice when staff failed to obtain physician orders for care of a continuous positive airway pressure machine (CPAP - a treatment for sleep apnea (sleep disorder that causes people to stop breathing or breathe shallowly while they sleep)) and failed to consistently clean the CPAP canister, tubing, and face mask for one resident (Resident #53) with a CPAP. The facility census was 65. 1. Review of Resident #53's face sheet showed: -admission date of 10/25/24; -Diagnosis included chronic respiratory failure with hypoxia (inadequate oxygen in the body tissues). Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 10/31/24, showed the following: -Cognitively intact; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document assessment for risk for entrapment and obtain informed consent prior to bed rail use for one resident (Resident #23) out of 17 sampled residents. The facility census was 65. Review showed the facility did not provide a policy regarding bed rail use. 1. Review of Resident #23's face sheet (brief look at resident information) showed the following information: -admission date 10/15/22; -Diagnoses included acute metabolic acidosis (too much acid in the blood). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 10/31/24, showed the resident required supervision for rolling from left to right and required substantial to maximum assistance from staff for moving from lying on the back to sitting on the side of the bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a complete and effective infection control program when staff failed to follow hand hygiene procedures and handle equipment in a manner to prevent transmission of infections agents per standards of practice for one resident (Resident #23) out of 17 sampled residents. The facility census was 65. Review of the facility's policy titled, Infection Prevention Annual Plan and Program Evaluation, dated 05/24, showed the following information: -Maintain a sanitary environment to minimize, reduce, or eliminate the risk of infection and communicable disease; -Ensure safe practices for cleaning and disinfecting environmental surfaces; -Ensure proper handling, storage, and disinfection of multi-patient use medical equipment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection control program when the facility failed to implement an enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities) policy timely and when staff failed to follow infection control practices, per standard of practice, when proving would care to residents (Resident #1 and Resident #2) putting the wounds at risk for contamination. The facility census was 67. Review of the facility's policy titled, Enhanced Barrier Precautions for Long Term Care, IP02-08, effective 09/2024, showed the following: -It is the policy of the facility to implement EBP for the prevention of transmission of MDROs; [...]