Parkview Healthcare Center

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the regular posted menu reflected the residents' food preferences for one of 14 final sampled residents (Resident 2) and one nonsampled resident (Resident 32). * Resident 2 and 32's food preferences were not honored. In addition, there was no alternate menu and posted for the residents who preferred Hispanic food. These failures had the potential to result in decreased meal satisfaction, reduced meal intake, unintended weight loss, and a negative impact on residents' psychosocial well being.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the food preferences were honored for one of 14 final sampled residents ( Resident 2) and three of seven nonsampled residents (Resident 29, 18, and 30). * The facility failed to ensure Resident 2's food preferences were honored when he stated he did not want to receive only Hispanic food; however, he continued to be served Hispanic food. * The facility failed to ensure food preferences for Residents 18, 29, and 30 were honored when they all preferred to have Mexican food. These failures had the potential for decreased meal intake, weight loss, and a negative impact on the residents' psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen (30 out of 35 residents were receiving food prepared in the kitchen). * The facility failed to ensure food preparation equipment was air dried. * The facility failed to ensure the safe storage of food items. * The facility failed to ensure kitchen equipment was maintained in a sanitary condition. * The facility failed to ensure appropriate beard restraint was worn by an outside vendor technician inside the kitchen. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on interview, medical record review, facility document review, and the facility P&P review, the facility failed to ensure two of two final sampled resident (Residents 4 and 28) reviewed for hospice services had received coordinated hospice services. * The facility failed to ensure Hospice A staff followed the established visit calendar. In addition, Hospice A skilled nursing visits progress notes were not available in Resident 4's medical record. * The facility failed to ensure Resident 4's hospice plan of care was incorporated into the facility's care plan. * The facility failed to ensure Hospice A was notified when morphine (narcotic pain medication) and oxygen orders were discontinued by the facility for Resident 4. In addition, the facility failed to ensure Hospice A medication list contained dosages of the medications for Resident 4. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain infection control practices to help prevent the development and transmission of diseases and infection. * The facility failed to follow infection control practices to properly disinfect the facility and residents' soiled laundry. * The facility failed to ensure the decorative fountain was monitored and maintained to minimize the growth and spread of waterborne pathogens and other contaminants. * The facility failed to maintain an accurate infection control surveillance for Resident 11. * The facility failed to ensure the staff offered hand hygiene to the residents prior to meal service. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and functional environment in one of 17 rooms (Room A) observed. * The facility failed to ensure Room A's ceiling vents were free of black, two resident-use cabinets had intact knobs and the shared restroom had no lifted floor tile. This failure posed a risk to the residents' ability to reside in a clean, safe, and homelike environment.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 24 and 35) reviewed for unnecessary medications were monitored appropriately for the use of the psychotropic medications. * Resident 24's orthostatic hypotension was not completed as ordered in both lying down and seated positions. In addition, the resident's medical record failed to show documentation of the resident's refusal of the orthostatic hypotension monitoring and if the physician was notified of the resident's refusal. * The facility failed to ensure the manifestation being monitored for Resident 35 matched with the behavior monitoring documentation supporting the use of the resident's psychotropic medications. These failures had the potential to negatively impact the residents' health outcomes and well-being.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to provide written notification to the resident and/or the resident's representative of the transfer, reason for the transfer, and facility's bed hold policy when the resident was transferred to the acute care hospital for one of two residents (Resident 38) reviewed for discharge. * The facility failed to provide written notification to Resident 38 and/or the resident's representative of the transfer, reason for the transfer, and the facility's bed hold policy when the resident was transferred to the acute care hospital on 5/13/26. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to revise the comprehensive plan of care to reflect the resident's current care needs and appropriate interventions for one of 14 final sampled residents (Resident 20). * The facility failed to ensure the care plan for Resident 20's basal cell cancer (type of skin cancer) lesion (damaged tissue) on left side of her nose was revised to include the regular trimming of the fingernails, despite the resident's known episodes of picking at the wound and the resident being observed with long, pointy fingernails. This failure posed the risk of not providing Resident 20 with individualized and person-centered care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide treatment and care in accordance with the professional standards of practice for two of 14 final sampled residents (Residents 7 and 20). * The facility failed to ensure Resident 20's nails were trimmed regularly to prevent her from picking or scratching the wound on the bridge of her nose. This failure had the potential to contribute to continued trauma to the wound site, delayed healing, increased risk of infection, and further deterioration of the resident's skin integrity. * The facility failed to ensure Resident 7 had a physician's order and care plan for the application of bilateral heel protectors (a quilted boot like device secured with hook and loop tape to prevent heel breakdown) or bilateral hand rolls (a soft padded device placed in the palm to prevent hand contracture). [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the appropriate care and services for the use of the GT for one of four sampled residents (Resident 27) reviewed for GT use. * The facility failed to ensure Resident 27's GT tubing was not touching the floor. In addition, the facility failed to clean the syringe used to flush and administer medications via GT after use. These failures posed the risk of complications related to Resident 27's GT.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary pharmaceutical services to ensure accurate administration of the medications: * The facility failed to ensure three unknown pills were properly wasted. This failure posed the risk of medication diversion. * The Administrator, who was not a licensed nurse, had a key to the narcotic destruction storage cabinet. This failure resulted in unauthorized access to controlled substances. * The storage closet used to store enteral feedings did not have a thermometer or temperature log. This failure posed a risk of the enteral products not to be maintained at appropriate room temperature. * Resident 27's stool softener (docusate sulfate) was not held, when Resident 27 had episodes of loose bowel movements. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's medical record was accurate for one of 14 final sampled residents (Resident 28). * Resident 28's POLST was inaccurate when it showed the resident's DPOA had designated Family Member 1 as the Health Care Agent. * The facility failed to complete a Significant Change MDS when Resident 28's hospice services were discontinued. * Resident 28's MDS assessment was incorrectly coded to show the resident received hospice services when services had already been discontinued. These failures resulted in incomplete and inaccurate medical records, which have the potential to negatively impact continuity of care and clinical decision making.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to implement the facility's antibiotic stewardship program to ensure timely physician notification for one nonsampled resident (Residents 11) who received antibiotics for infections that did not meet McGeer's criteria. * The facility failed to ensure Resident 11's symptoms met the criteria for cellulitis/soft tissue/wound infection. In addition, the facility failed to notify the physician the resident's symptoms did not meet the criteria, and to reassess the need for continued antibiotic therapy. These failures had the potential to result in unnecessary antibiotic use and contribute to the development of multidrug resistant organisms (MDROs).

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' care equipment was maintained in a safe operating condition. * LVN 3 was observed using a Velcro wrist blood pressure (BP) cuff machine during a medication administration observation. The BP (blood pressure) machine was used on multiple residents, was not serviced or maintained as per the manufacturer's manual and was not properly cleaned according to the manual's instruction. This failure posed the risk of cross contamination and inaccurate blood pressure readings for the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the complete medical record was maintained for one of three sampled residents (Resident 1). * Resident 1's Elopement Evaluation was not completely filled out. * Resident 1's medical record failed to show documentation the resident was monitored for a change in condition on 5/3/25, for the 0700-1500 hours shift.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided to prevent the decline in the ROM functions for one of two final sampled residents (Resident 2) reviewed for ROM functions. * The physician's order to apply the bilateral AFOs to Resident 2's lower extremities was not followed. In addition, Resident 2's skin was not assessed when the AFO was applied. These failures had the potential for Resident 2 to sustain a decline in ROM functions, leading to muscle atrophy (loss of muscle mass and strength) and decrease in functioning.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of four final sampled residents (Resident 1) reviewed for the prevention of accident hazards. * The facility failed to implement the floor mat on the left side of Resident 1's bed for safety in accordance with the physician's order. This failure had the potential for the resident to be at high risk of serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of 15 final sampled residents (Residents 2, 3, and 14) reviewed for oxygen therapy. * The facility failed to ensure Resident 2's nasal cannula oxygen tubing was not touching the floor. * The facility failed to follow the physician's order for Residents 3 and 14's oxygen therapy. In addition, the facility failed to ensure Residents 3 and 14's nasal cannula oxygen tubing were not touching the floor. These failures had the potential for the residents to not receive the appropriate care and may negatively impact on the residents' medical conditions.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation and administration of the medications for one of 15 final sampled residents (Resident 16) and one nonsampled resident (Resident 27). * The facility failed to ensure the injection sites for the insulin medication were documented for Resident 16. * The facility failed to ensure Resident 27 had a physician's order to crush the medications when the licensed nurse crushed and administered the resident's medications orally during the medication administration observation. These failures posed the risk for medication administration errors and the potential to negatively affect the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and disposal of the medications. * The facility failed to ensure Medication Storage Room A, Medication Carts A and B were maintained in a clean and sanitary manner, and the oral medications and external medications were stored separately . * The facility failed to ensure Medication Cart B was locked when left unattended. * The facility failed to ensure the medication was labeled with an opened date and dispose of the discontinued medications in Medication Cart A. These failures had the potential for the medications to lose the stability and effectiveness, cause medication errors and negatively impact the residents' well-being

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the scoop used for food portioning and measuring cups was air dried prior to storing. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential for cross contamination and foodborne illnesses for the residents consuming the food prepared in the facility's kitchen.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. A plan to maximize recruitment and retention of direct care staff; and 3. A contingency plan for staffing needs. This failure had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the facility's monthly Infection Prevention and Control Surveillance Logs were accurate. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. * The facility failed to ensure the proper handling of clean linens. * The facility failed to perform hand hygiene while providing care to Resident 31. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete for three of 15 final sampled residents (Residents 14, 16, and 28) and one nonsampled resident (Resident 17) reviewed for the side rail use. These failures had the potential to negatively impact the residents, resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 15 sampled residents (Resident 25) was revised to reflect Resident 25's current care needs and interventions. * The facility failed to ensure Resident 25's comprehensive care plan was revised to show the resident's current suprapubic indwelling urianry catheter (a flexible tube that is used to drain urine from the bladder through a small incision in the lower abdomen) size. This failure posed the risk of not providing necessary care and services to meet Resident 25's needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure the nurse staffing information was posted on a daily basis. This failure had the potential for the residents, staff, and visitors to not know the facility's daily nurisng staffing.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in one of one garbage dumpster. This failure had the potential to attract pest/rodents that carried diseases.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 17) had accurate and complete medical record. * The facility failed to ensure Resident 17's TAR for April 2025 was complete. This failure had the potential for the resident's health care need not to be met as the medical record was incomplete and inaccurate.

Inspectors wroteBased on observation and interview, the facility failed to ensure Room A did not accommodate more than four residents. At the time of the survey, there were five occupied beds in the room, which posed the risk of five residents sharing one room.

Inspectors wroteBased on observation and interview, the facility failed to ensure Room A measured at least 80 square feet per resident. Room A was a five-bed room, which measured 78.4 feet per resident if all the beds were filled. At the time of the survey, the room was occupied by five residents. This failure had the potential to negatively impact the residents' quality of life.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the IP had the knowledge of the Pneumococcal immunization update per the CDC's guidelines. In addition, the facility failed to ensure the IP had the appropriate knowledge to implement the enhanced barrier precautions with the facility's residents needed to be placed on a special precautions. These failures had the potential for the residents not to receive timely the appropriate type of pneumonia immunization placing the residents at risk for developing pneumonia (infection of the lungs that causes inflammation of air sacs in one or both lungs which may fill with fluid), and potential for spread of infection.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer PCV 15/PCV 20 (PCV 15 protects against two additional serotypes and PCV 20 protects against seven additional serotypes involved in cases of invasive pneumococcal disease (IPD) and pneumonia) immunizations for 20 of 20 nonsampled residents (Residents 1, 3, 4, 5, 6, 8, 13, 15, 16, 18, 19, 21, 23, 24, 25, 27, 29, 30, 31, and 33) reviewed for pneumococcal vaccination (a vaccine given to protect the resident from pneumococcal disease) in accordance with the CDC's recommendations. No tracking system was in place for pneumococcal vaccine history. These failures increased the residents' risk for being inadequately vaccinated for the pneumococcal disease and its associated complications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify five of five residents reviewed for bed hold notification (Residents 10, 22, 32, 35, and 38) of their rights to a bed hold (holding or reserving a resident's bed while the resident in the acute care hospital) policy upon transfer to the acute care facility. This failure had the potential for residents or their representatives to be unaware of his or her rights to request a bed hold upon transfer.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDSs for 11 of 17 reviewed residents (Residents 3, 15, 16, 18, 19, 21, 23, 25, 27, 31, and 33) were accurate. This failure posed the risk of the residents not receiving an individualized plan of care on the residents' specific needs.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure to provide the necessary services to attain or maintain the highest practicable well-being for three of three reviewed residents (Residents 20, 22, and 36). * The facility failed to ensure Resident 22's abduction pillow and bilateral heel protectors were in place while in bed per the physician's orders. In addition, the facility failed to ensure Resident 22 did not wear the left knee immobilizer while Resident 22 was in bed per the physician's order. The facility failed to ensure Resident 22 had other bowel management medication intervention as needed. * The facility failed to ensure the hospice and facility collaborated in the hospice care for Residents 20 and 36. * The facility failed to ensure a hospice care member participated in Resident 36's Quarterly IDT meeting.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the cutting boards and kitchen equipment were in sanitary conditions * The facility failed to ensure the food items were discarded on or before the best by date * The facility failed to ensure the temperature of the food items were checked prior to preparing or distributing to residents * The facility failed to ensure the staff's personal belonging was not stored in the kitchen's clean utility room * The facility failed to ensure the kitchen staff maintained proper hand hygiene * The facility failed to ensure the staff covered food during transportation through the outdoor dry storage room and back inside facility * The facility failed to ensure Resident 4 received the correct [...]

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to ensure the EBP (Enhanced Barrier Precautions) was practiced for the residents with an indwelling urinary catheter (Resident 20) and GT (Residents 2, 9, and 36). * The facility failed to ensure LVN 2 wore proper PPE when administering medication through a GT for Resident 3. * The facility failed to ensure the Yankuer Suctioning (oral suctioning tool) was stored separately with opened date for Resident 11. * The facility failed to ensure LVN 1 performed hand hygiene in between changing gloves when providing wound treatment to Resident 22. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff provided care and promoted dignity and respect for three of 11 residents reviewed for dignity and respect (Residents 5, 8, and 35). * CNA 3 was observed standing over Resident 8 while assisting the resident with meals. * CNA 2 was observed standing over Resident 35 while assisting the resident with meals. * The facility failed to ensure Resident 5's body was fully covered while being transported from the shower room to her room. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to fully inform the resident or responsible party of their bed with side rails, the entrapment assessment for Zone 6, and the treatment alternatives or options for two of four sampled residents (Residents 9 and 32). This failure had the potential for Residents 9 and 32 and their responsible parties to not make the informed decisions regarding the care and treatment of bed side rail use.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the care needs for one nonsampled residents of 38 residents in the facility (Resident 37). * The facility failed to ensure Resident 37's call light was within the resident's reach. This failure had the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care and services to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one resident (Resident 26) reviewed for resident's choice and food preferences with meals was honored. This failure had the potential risk for a diminished quality of life and impact resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to inform and provide the written information regarding the rights to formulate the advance directives to one of three reviewed residents (Resident 35). In addition, the facility failed to ensure the copy of the advance directives was readily available in the residents' charts for two of three reviewed residents for advance directives (Residents 10 and 12). These failures had the potential for the facility to provide treatment and services against the resident's wishes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the resident and/or their representative of the transfer/discharge and reasons for the transfer in writing for one of five residents reviewed for hospitalization (Resident 32). This failure had the potential for the resident and their representative not knowing about the appeal process should the resident and their representative believe the transfer or discharge was inappropriate or involuntary.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide a summary of the baseline care plan for one of one reviewed resident (Resident 441). This failure had the potential for inappropriate interventions and care for Resident 441.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to develop and implement the comprehensive plan of care to reflect the individual care needs of one of 14 sampled residents (Resident 22). The facility failed to develop a care plan problem to address Resident 22's noncompliance with a physician's order to apply her abduction pillow at all times while in bed. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 22.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of one resident reviewed for activity (Resident 11). The facility failed to provide activities for Resident 11 which met his identified interests. This failure had the potential for Resident 11 to experience feelings of social isolation and frustration.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of two residents reviewed for the use of indwelling urinary catheter (Residents 20 and 35) were provided with the necessary indwelling urinary catheter care to prevent UTI. The facility failed to ensure Resident 20's indwelling urinary catheter orders followed the CDC's guidelines. These failures had the potential to put Residents 20 and 35 at risk for UTI.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the nutrition needs were met for one of two residents reviewed for nutrition (Resident 32). * The facility failed to ensure Resident 32 was offered alternative when Resident 32 consumed less than 50% of his meal tray. This failure had the potential to compromise Resident 32's nutritional status. Findings. On 4/2/24 at 0802 hours, an interview was conducted with Resident 32. Resident 32 stated he had been losing weight; however, he thought the current weight was his ideal weight. Medical record review for the Resident 32 was initiated on 4/2/24. Resident 32 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 32's Vital Signs Grid dated 4/5/24, showed following weights: - 3/4/24, 174 lbs (pounds); - 2/26/24, 174 lbs; - 2/19/24, 168 lbs; [...]

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure three of four sampled residents with GT (Residents 2, 9, and 36) were provided care as evidence by: * The facility failed to ensure CNA 6 worked within their scope of practice as shown on the facility's document titled Patient Care Assistant - CNA Job Description. * The facility failed to ensure Residents 2, 9, and 36's GT tubing were properly labeled. These failures posed the risk for negative outcomes for the residents with GT.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for two of three residents reviewed for respiratory care (Residents 2 and 17). * The facility failed to provide oxygen therapy as per the physician's order for Resident 17. * The facility failed to ensure Resident 2's suction machine canister was discarded after use and failed to ensure an oxygen bag was available and suction machine bag was dated. These failure posed the risk for residents' safety and respiratory related complications including infection.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the ongoing assessment before, during, and after dialysis treatments for one of one resident reviewed for dialysis services (Resident 10) was conducted as evidenced by: * Resident 10's dialysis communication forms dated 4/2 and 4/4/24, were incomplete. This failure had the potential of not identifying negative outcomes for the dialysis resident (Resident 10).

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to meet the needs of residents. The emergency kit for the facility's oral medications was not replaced in a timely manner. This failure had the potential for to contribute to a decreased availability of medications in an emergency. Findings. Review of the facility's P&P titled Availability and Use of Emergency Medication Kits revised January 2020 showed the facility must notify pharmacy when an emergency kit was opened and needs replacement. Further review of the P&P showed the pharmacy will then replace the open kit on the next working day. On 4/3/24 at 1518 hours, during the inspection of Medication Storage room [ROOM NUMBER] with the IP, the emergency kit for the oral medications was observed to be locked with a white zip tie. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for two of five residents reviewed for unnecessary medications (Residents 22 and 32). * The facility failed to ensure the Pharmacy Consultant's recommendation to provide duration of the therapy for enoxaparin (its brand name, Lovenox, an anticoagulant used to decrease the clotting ability of the blood) for Resident 22 was acted upon. This failure had the potential to put Resident 22 at risk for adverse consequences related to the medication. * The failed to ensure the physician provided a rational when no action was taken for the Pharmacy Consultant's recommendation if clinically feasible to provide a duration of therapy for Lovenox for Resident 32. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from the unnecessary psychotropic medications (any drug that affects brain activity associated with mental processes and behavior) for two of two residents reviewed for antipsychotic medications (Residents 20 and 35). * Resident 35 had an order for olanzapine (its brand name, Zyprexa, an antipsychotic medication). The facility failed to ensure Resident 35 was assessed for Abnormal Involuntary Scale (AIMS, a rating scale that was designed in the 1970s to measure involuntary movements known as tardive dyskinesia (TD) for the use of olanzapine (Zyrexa). * Resident 20 had an order for bupropion (Wellbutrin) (antidepressant medication) and quetiapine (Seroquel) (antipsychotic medication). [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were not left unattended on the medication cart for one of two residents reviewed for medication administration (Resident 3). This failure had the potential for medication diversion.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the puree recipes and renal and CCHO menus were followed for three residents (Residents 11, 18, and 35) with puree diet, two of four residents (Residents 11 and 18) with a puree renal diet, and 10 of 32 residents (Residents 5, 10, 11, 13, 16, 17, 18, 28, 29, and 35) on CCHO diet as evidenced by: * The facility failed to ensure the puree recipes were followed. * The facility failed to ensure two residents (Residents 11 and 18) on a renal pureed diet did not receive roasted red potatoes. * The facility failed to ensure the residents with a CCHO diet (Residents 5, 10, 11, 13, 16, 17, 18, 28, 29, and 35)received plain ice cream as shown on the Spring Cycle Menu Week 1 dated for 4/3/24. [...]

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the food test tray was prepared in an appetizing temperature as evidenced by: * Test tray temperatures were below the recommended temperature for hot meats, vegetables, and potatoes. * Three of 38 residents (Residents 12, 26, and 32) had complained the food was cold These failures posed the risk for not providing palatable and appetizing food for the residents receiving a meal tray from the kitchen.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for three of 14 final sampled residents (Residents 26, 32, and 35) was complete and accurate. * The facility failed to ensure an active physician's orders for Resident 26 to continue no weight bearing status to the left upper extremity and to continue to use a left arm sling for support were discontinued. * The facility failed to ensure Resident 35's physician's order for Dulcolax (laxative) medication was accurate. These failures had the potential for the resident's accurate clinical status not being available and communicated to care team.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the hospice and facility staff worked collaboratively together in the plan of care for two of three hospice residents (Residents 20 and 36) as per the hospice contract agreement. This failure had the potential of Residents 20 and 36 to not receive hospice care as per the hospice agreement.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to follow up when the residents' beds failed on the entrapment assessments zone for two of three residents reviewed for bed rails (Residents 9 and 32). * The facility failed to ensure Residents 9 and 32's side rails were reassessed after failed Zone 6 measurement was noted. This failure had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the quarterly MDS assessment was completed within 14 calendar days of the Assessment Reference Date (ARD) for one of one reviewed resident (Resident 21). This failure had the potential of not identifying each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessments once the health problems had been identified.

Inspectors wroteBased on interview and medical record review, the facility failed to transmit the MDS timely for one of one resident reviewed (Resident 14). This failure had the potential for not providing care to meet the resident's care needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure Room A did not accommodate more than four residents. At the time of survey, there were five occupied beds in the room, which posed the risk of five residents sharing one room.

Inspectors wroteBased on observation and interview, the facility failed to ensure Room A measured at least 80 square feet per resident. Room A was a five-bed room, which measured 78.4 feet per resident if all the beds were filled. At the time of the survey, the room was occupied by five residents. This failure to have the designated square footage created the potential to negatively impact the residents' quality of life.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the head and neck support for one of five sampled residents' (Resident 1) highbacked personalized wheelchair was in the correct position when Resident 1 left the facility for an outing with her family on 12/30/23. This failure resulted in Resident 1's head being tilted to one side and incorrectly aligned in her wheelchair, causing pain, and psychological distress, which had the potential to negatively impact the resident's well-being. Findings Medical record review for Resident 1 was initiated on 1/16/24. Resident 1 was originally admitted to the facility on [DATE],and readmitted on [DATE]. Resident 1 had a diagnosis of MS. Review of Resident 1's H&P examination dated 10/3/23, showed Resident 1 had the capacity to understand and make medical decisions. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the proper use of bed rails for six of six sampled residents (Residents 1, 2, 3, 4, 5, and 6). * Resident 1 was observed with bilateral bed rails elevated, however, had a physician ' s order, assessment, and care plan problem for the right siderail use only. * Resident 2 was observed with bilateral bed rails elevated, with no physician ' s order, assessment, nor care plan problem in place. * Resident 3 was observed with upper and lower left ½ (half) bed rails elevated. Resident 3 did not have a physician ' s order, assessment, or care plan problem for the use of the bed rails. * Resident 4 was observed with bilateral ½ length bed rails elevated, with the right siderail padded. Resident 4 ' s physician ' s order was only for the left padded half bed rail. [...]