Parkview Heights Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for four residents: Resident (R) 3, R2, R14 and R30, related to anticoagulant medication (medication used to prevent clotting).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident (R) 7 received assistance with activities of daily living (ADL) of cleansing off her face.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and implement resident-centered fall interventions for Resident (R) 7, R2, and R13 who were at risk for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident (R)2 received the necessary nutritional support when staff failed to provide a breakfast meal for several days in May 2026.

Inspectors wroteBased on record and interview, the facility failed to ensure all residents were free from significant medication errors when a staff member administered 30 units of insulin to Resident (R)13, who was not a diabetic.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided cognitively impaired Resident (R) 7 with her prescribed nectar thickened (liquid with slightly higher viscosity that pour easily but leave a coating on the glass or spoon, they slow down the swallowing process to prevent fluids from entering the lungs) liquids.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 7 with open wounds to her knees. Additionally, the facility failed to ensure adequate hand hygiene during a dressing change for R7 and perineal care for R2. The facility failed to properly transport clean personal linens.

Inspectors wroteBased on interview and record review the facility failed to offer and provide or obtain an informed declination for the COVID-19 vaccine (a vaccine designed to prevent highly contagious respiratory virus) for Resident (R) 2. Additionally, the facility failed to maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status.

Inspectors wroteThe facility reported a census of 35 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on eight dates between 04/01/23 and 06/30/23 and five dates between 10/01/23 and 12/31/23. Findings Included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY),Quarter 3 2023 (April 1- June 2023) revealed lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: [...]

Inspectors wroteThe facility reported a census of 35 residents with 14 residents selected for review. Based on observation, interview and record review, the facility failed to complete and analysis of findings for the Minimum Data Set (MDS), triggered Care Area Assessments (CAA) to complete a comprehensive assessment and develop a care plan for four of the 14 residents selected for review. This included Resident(R) 15, for Delirium; [...]

Inspectors wroteThe facility reported a census of 35 residents with 14 residents sampled, including two residents reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to complete a comprehensive care plan for one Resident (R)33, regarding the use of a Continuous Positive Airway Pressure (CPAP-a non-invasive positive airway pressure) for one Resident (R)33.

Inspectors wroteThe facility reported a census of 35 residents with 14 residents sampled, including two residents reviewed for positioning. Based on interview, record review, and observation, the facility failed to ensure appropriate positioning for one Resident (R)4, while in her specialized wheelchair.

Inspectors wroteThe facility reported a census of 35 residents with 12 residents sampled, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide safe transfers for two Residents (R)4 and R 15, and failed to provide safe wheelchair transport for one R 28.

Inspectors wroteThe facility reported a census of 35 residents with 14 residents sampled, including two residents reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to obtain a physician's order for the use of a Continuous Positive Airway Pressure (CPAP-a non-invasive positive airway pressure) for one Resident (R)33.

Inspectors wroteThe facility identified a census of 33 residents. Based on record review, and interviews, the facility failed to provide a certified infection preventionist to oversee the facility's Infection Prevention and Control Program (IPCP). This deficient practice placed all residents at increased risk of infections related tor lack of identification, tracking/trending, and treatment of infections.

Inspectors wroteThe facility reported a census of 33 residents with 13 selected for review. Based on observation, interview, and record review, the facility failed to conduct an assessment for Resident (R)15 to determine the safety for self-administration of vaporizing rub ointment. This placed R15 at risk to use the vaporizing rub ointment in an unsafe manner.

Inspectors wroteThe facility reported a census of 33 residents with 13 selected for review. One resident was reviewed for elopement (when a cognitively impaired resident leaves the facility without staff knowledge and /or supervision). Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one of the residents, Resident (R)4, for wander/elopement alarm (device worn on the resident or attached to assistive device such as walker or wheelchair or other personal belongings, to alert the staff when a resident nears or exits a specific area of the building). This placed the resident at risk for uncommunicated care needs.

Inspectors wroteThe facility reported a census of 33 residents with 13 selected for review. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan to direct staff care for one of the resident's, Resident (R)4, to address her risk of elopement (when a cognitively impaired resident leaves the facility without staff knowledge and/or supervision). This placed the resident at risk for uncommunicated care needs.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 13 residents with two reviewed for care plan revisions. Based of observations, record review, and interviews, the facility failed to implement updated fall interventions after Resident (R) 7 fell while using the restroom. This deficient practice placed R7 at risk for preventable falls and injuries due to uncommunicated care needs. Findings Included: [...]

Inspectors wroteThe facility identified a census of 33 residents. The sample included 13 residents with 13 reviewed for quality of care. Based on observations, record review, and interviews, the facility failed to follow physician ordered instructions to weigh Resident (R)3 daily. The facility additionally failed to report weight changes to the medical provider as instructed in the order parameters. This deficient practice placed R3 at risk for complications related to edema (swelling resulting from an excessive accumulation of fluid in the body tissues). Findings Included: [...]

Inspectors wroteThe facility identified a census of 33 residents. The sample included 13 residents with three reviewed for accidents. Based on observations, record review, and interviews, the facility failed to identify and/or address causative factors for Resident (R)27 resulting in repeated falls. The facility additionally failed to identify R15's potentially flammable use of petroleum-based vapor rub medication with supplemental oxygen and failed to monitor R4's Wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort). This deficient practice placed the residents at risk for preventable injuries and accidents. Findings Included: [...]

Inspectors wroteThe facility identified a census of 33 residents. The sample included 13 residents with three reviewed for bowel and bladder management. Based of observations, record review, and interviews, the facility failed to provide individualized toileting interventions for Resident (R)27. This deficient practice placed R27 at risk for urinary tract infections and preventable falls. Findings Included: [...]

Inspectors wroteThe facility reported a census of 33 residents with 13 selected for review including one resident reviewed, Resident (R)29, for presence of a percutaneous endoscopic gastrostomy (PEG - tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) tube. Based on observation, interview, and record review, the facility failed to flush the PEG tube daily, which was not being utilized to administer food, fluids, or medications, to ensure patency of the tube. This placed the resident at risk for complications related to her PEG tube.

Inspectors wroteThe facility reported a census of 33 residents with 13 selected for review including three residents reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to change the oxygen nasal cannula and the nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) kit tubing for Resident (R)15. These practices increased the risk of R15 for developing a respiratory infection.