Parkview Manor Care Center

Inspectors wroteBased on clinical record review, staff and resident interviews, policy review and observations the facility failed to respond timely (defined as 15 minutes of less) to a resident's request for assistance for 2 of 3 residents reviewed (Residents #3 and #4). The facility reported a census of 27 residents.

Inspectors wroteBased on observation, staff interviews and policy review, the facility failed to maintain a sanitary kitchen and dining room. In addition, the facility failed to handle dishes in a sanitary manner to reduce the risk of cross contamination and food borne illness. The facility reported a census of 26.

Inspectors wroteBased on observation, family, and staff interview, the facility failed to provide a homelike environment by keeping register covers on the floor in 4 out of 4 resident rooms (Rooms #1, #6, #10 and #18). The facility reported a census of 26 residents.

Inspectors wroteBased on clinical record review, policy, and staff interview, the facility failed to notify the long-term care (LTC) Ombudsman for 2 of 2 residents who transferred to the hospital (Residents #6 and #24). The facility reported a census of 26 residents.

Inspectors wroteBased on clinical record review, policy and staff interview, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 2 residents reviewed with a new mental health diagnosis (Resident #24). The facility reported a census of 26 residents.

Inspectors wroteBased on observation, facility document review, and staff interviews, the facility failed to post the staff daily posting with the required staffing data. The facility reported a census of 26 residents.

Inspectors wroteBased on staff interview, facility investigation review, time card detail, and policy review, the facility failed to separate a staff member from dependent residents accused of alleged physical and verbal abuse that occurred on 8/30/24 around 11:30 PM in a timely manner for 1 of 13 residents reviewed for abuse (Resident #9). The staff member not only continued to work the rest of her shift on 8/30/24, they worked full shifts on 8/31/24, 9/1/24, and 9/2/24. Due to the facility failing to separate the alleged abuser from the alleged victim and/or other vulnerable residents, this resulted in an immediate jeopardy situation. The facility didn't initiate an investigation for the alleged abuse until 9/3/24. The Department notified the facility of the immediate jeopardy (IJ) on 9/24/24, that began on 8/30/24. The facility removed the immediacy on 9/24/24 after implementing the following: a. [...]

Inspectors wroteBased on staff interview, facility investigation review, clinical record review, and policy review, the facility failed to notify the Department of Inspections, Appeals and Licensing (DIAL) of alleged physical and verbal abuse that occurred on 8/30/24 around 11:30 PM in a timely manner. The Certified Nursing Aide (CNA) reported the alleged incident after first rounds on 8/30/24 to a Licensed Practical Nurse (LPN). The facility didn't start their investigation for the alleged abuse until 9/3/24 for 1 of 13 residents reviewed for abuse (Resident #9). The facility reported the incident to DIAL at approximately 1:00 PM on 9/3/24. The Department notified the facility of the immediate jeopardy (IJ) on 9/24/24, that began on 8/30/24. The facility removed the immediacy on 9/24/24 after completing the following: a. [...]

Inspectors wroteBased on clinical record review, staff interviews, observations, hospital record review, and policy review, the facility failed to provide adequate nursing supervision to prevent accidents and injuries for 1 of 3 residents reviewed (Resident #21). On 9/17/24 Resident #21 attempted suicide by wrapping the bed remote cord around his neck twice which resulted in transfer to the hospital for a psychiatric evaluation and medication changes at the facility. Following his return, the facility gave him back his television, but failed to secure the television cords, cable cords, and a power cord under the bed to prevent access. Due to Resident #21's recent incident with wrapping a cord around his neck, this resulted in an immediate jeopardy situation. The State Agency informed the facility of the Immediate Jeopardy that began on 9/24/24 at 5:15 PM. [...]

Inspectors wroteBased on record review, staff and family interviews and facility policy the facility failed to complete and document treatment to a stage 2 pressure ulcer consistent with professional standards of practice for 1 of 2 residents reviewed (Resident #8). The facility reported a census of 26 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. [...]

Inspectors wroteBased on clinical record review, resident interview, staff interview, family interview, facility records and facility policy review the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility for 4 residents reviewed (Residents #23, #21, and #10). The facility reported a census of 26 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to have an adequate clinical rationale for a gradual dose reduction (GDR) declination (decline) for 4 out of 5 residents reviewed for unnecessary medications (Residents #3, #8, #9, #11). The facility reported a census of 26 residents.

Inspectors wroteBased on clinical record review, and staff interviews, the facility failed to ensure resident's current code status was available for 1 out of 13 residents reviewed (Resident #130). The facility reported a census of 26 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to notify the Physician and family regarding the development of a new pressure ulcer for 1 of 2 residents reviewed (Residents #15). The facility reported a census of 26 residents.

Inspectors wroteBased on clinical record review, staff interviews, and review of Medicare guidelines, the facility failed to provide a notice of Medicare Non coverage 48 hours in advance of services ending. In addition, the facility failed to provide the correct Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNF ABN) form for 1 of 3 residents reviewed (Resident #133) whose skilled stay ended and they continued to reside in the facility. The facility reported a census of 26 residents.

Inspectors wroteBased on clinical record review, personnel record review, staff interviews, and policy review, the facility failed to protect a resident from verbal abuse by a staff member for 1 of 13 residents reviewed for abuse (Resident #9). The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to develop a Care Plan to address risk factors and interventions for 1 out of 13 residents (Residents #21) reviewed for comprehensive Care Plans. The facility reported a census of 26 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to revise a Care Plan for 3 of 13 residents reviewed (Residents #15, #21, #6). The facility reported a census of 26 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to follow physician orders regarding checking placement of a jejunostomy tube (J tube: a soft plastic tube that is surgically inserted into the small intestine to provide nutrition and medicine until a person can eat normally) for 1 of 1 resident reviewed (Resident #10). The facility reported a census of 26 residents.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to have a Physician or a Non Physician Practitioner (NPP) provide a face to face visit, including a comprehensive assessment, once every 60 days for 1 of 5 residents (Residents #15) reviewed for Physician Services. The facility reported a census of 26 residents.

Inspectors wroteBased on staff interviews, clinic record review, and policy review, the facility failed to administer medication appropriately for 1 out of 13 residents (Resident #1) which resulted in a significant medication error. Resident #1 received Xanax and morphine that wasn't prescribed to her, but to Resident #6; who had the same first name as Resident #1. The facility reported a census of 26 residents.

Inspectors wroteBased on observation, record review, document review and staff interview the facility failed to provide appropriate infection prevention practices by not following guidelines for enhanced barrier precautions and medication administration for 3 out of 3 residents reviewed (Residents #3, #10, and Resident #1). The facility reported a census of 26 residents.

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to ensure that 1 of 3 residents reviewed were treated with dignity and respect (Resident #1). On 3/23/24 Staff A, Certified Nursing Assistant (CNA) yelled at Resident #1 in a disrespectful and undignified manner using foul language The facility reported a census of 28 residents.

Inspectors wroteBased on record review, policy review, and staff interview the facility failed to answer call lights in a reasonable amount of time (15 minutes or less) for 12 of 55 documented call light alerts reviewed on Saturday 12/30/2023 from the hours of 12:25 AM to 3:57 PM. The facility reported a census of 25 residents

Inspectors wroteBased on record review, resident representative interview, staff interviews, and facility policy review the facility failed to provide notification of changes for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 25 Residents.

Inspectors wroteBased on observation, staff interviews, and record review the facility failed to provide privacy while a resident changed clothes for 1 of 1 resident reviewed (Resident #22). The facility reported a census of 25 residents.

Inspectors wroteBased on record review, staff interviews, and Resident Assessment Instrument (RAI) Manual the facility failed to complete the Minimum Data Set (MDS) within 14 days of starting Hospice services for 1 of 3 residents (Resident #7). The facility reported a census of 25 Residents.

Inspectors wroteBased on clinical record review, staff interviews, direction from the Resident Assessment Instrument, and policy review, the facility failed to assure each resident received an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment for 1 of 3 residents reviewed for Accuracy of Assessment (Resident #22). The facility reported a census of 25 residents.

Inspectors wroteBased on clinical record review, family interview, staff interviews, and policy review the facility failed to complete a base line Care Plan within 48 hours of admission for 1 of 3 new residents sampled for review (Resident #78). The facility reported a census of 25 residents.

Inspectors wroteBased on clinical record review, interview, and policy review the facility lacked a discharge summary including a recapitulation of a resident's stay for 1 of 1 discharged residents reviewed in the closed record sample (Resident #26). The facility reported a census of 25 residents.

Inspectors wroteBased on observation, staff interviews, resident interviews and policy review, the facility failed to provide proper functioning call system to resident (Resident #14) and proper functioning response systems to staff (indicated wrong times on response and call pendant did not work). The facility reported a census of 25. The Minimum Data Set (MDS) for Resident #14 dated 10/18/23 listed diagnoses including complex conditions, hypertension, anxiety, history of falling, osteoarthritis, weakness, pain, and unsteady on feet. The MDS section for Brief Interview for Mental Status (BIMS) scored 15 indicated the resident cognition was intact. The Care Plan revised 9/3/22 documented self-care performance deficit, impaired visual function related to macular degeneration, bladder incontinence, weakness, and hyponatremia, required assistance of one person with bathing. [...]