Parkview Home

Inspectors wroteBased on interview and document review the facility failed to obtain a bed hold for 1 of 4 sampled residents (R24) reviewed for hospitalization

Inspectors wroteBased on interview and document review, the facility failed to revise the care plan for 2 of 12 sampled resident (R15 and R18) reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff had appropriately followed medication administration through to completion for 1 of 1 sampled resident (R4) with a nebulized (inhaled) medication by providing appropriate supervision and follow policy and procedure for the cleaning of the medication cup after administration was completed.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure documentation of 1 of 1 sampled resident's (R4) ability to self-administer medication was consistent and accurate throughout the medical record.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure 1 of 1 observed nebulizer (inhaled medication) medication cup was rinsed and left to air dry after each medication administration for 1 of 1 resident (R4) to prevent potential complication of infection.

Inspectors wroteBased on interview and document review, the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 18 residents.

Inspectors wroteBased on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 18 residents.

Inspectors wroteBased on interview, and document review, the Quality Assurance (QA) committee failed to ensure they received reports from the infection preventionist on the infection control program for 1 of 3 quarters reviewed.

Inspectors wroteBased on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employees would be able to return to work after an illness dependent upon their symptoms. In addition, the facility failed to ensure 2 of 5 (certified nursing assistant and dietary aide) had completed tuberculosis testing (TST) upon hire. This had the potential to affect all 18 residents in the facility

Inspectors wroteBased on interview and document review the facility failed to ensure the acting infection preventionist (IP) (who is the facility's director of nursing (DON)) had completed specialized training in infection prevention and control. This had the potential to affect all 18 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to provide mandatory training on 1 of 1 facility's specific Quality Assurance Performance Improvement (QAPI) Program to all staff to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how staff was to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. This had the potential to affect all 18 residents.

Inspectors wroteBased on interview and document review the facility failed to follow facility policies and ensure reports to the State Agency (SA) were submitted not later than 2 hours for an incident of potential abuse or neglect for 1 of 1 resident (R15) after the facility became aware of the incident.

Inspectors wroteBased on interview and document review the facility failed to throughly investigate an injury of unknown origin for 1 of 1 resident (R15).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food and beverages stored in the refrigerators, were labeled, dated and discarded properly. This deficient practice had the potential to affect all 21 residents who received food and beverages from the refrigerators.

Inspectors wroteBased on interview and document review, the facility failed to submit complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarters reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 21 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure 5 of 5 residents (R4, R15, R8, R1, R2) were offered or received pneumococcal vaccinations based on shared clinical decision-making in accordance with the Center for Disease Control (CDC) recommendations.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 1 resident (R19) who was observed to self administer a nebulizer and had been assessed as not safe to self administer medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to obtain and implement oxygen orders for 1 of 2 residents (R20) and reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure insulin was administered according to manufacturer's guidelines for 1 of 1 resident (R1) resulting in the potential for serious harm or death when R1 had to be sent to emergency department (ED) for hypoglycemia (low blood sugar (BS)) when staff administered R1's insulin without ensuring he ate within the required time frame of 5-10 minutes. The IJ began on 2/5/24, when licensed practical nurse (LPN)-A failed to follow manufacturer guidelines when administering Novolog (a rapid acting insulin) to R1. R1 was administered insulin at 11:14 a.m. without being fed any type of meal or sustenance within 5-10 minutes of administration and was subsequently sent to the ED with severe hypoglycemia for medical treatment. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure an emergency dental agreement had been completed which had the potential to affect all 22 residents residing in the facility reviewed during the extended survey.