Parkview Manor Nursing Home

Inspectors wroteBased on observation and interview, the facility failed to ensure food was not outdated, foods were thawed in a safe and sanitary manner, and the walk-in freezer and the floors of the walk-in cooler were kept in a sanitary manner in 1 of 1 kitchen. This has the potential to affect all 30 residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure employees were documented as having been tested and illnesses monitored and tracked to identify potential or actual correlation between residents with known COVID and staff exposure and/or subsequent illness, or indicate when an employee would be able to return to work (RTW) after illness, according to the Centers for Disease Control, for 7 of 9 staff (Nursing assistant (NA)-B, NA-C, NA-E, NA-F, NA-G, NA-H, and NA-I) with symptoms of COVID during an outbreak. This had the potential to affect 11 remaining residents who showed no documented signs and/or symptoms of COVID, but who may have been exposed to staff.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 infection preventionist (IP) had appropriate time allowed to dedicate to oversight of the infection control program. This had the potential to affect all 28 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to timely notify the physician for 1 of 1 sampled resident (R15) when she experienced worsening cough with no relief.

Inspectors wroteBased on interview and document review, the facility failed to accurately code medication on the Minimum Data Set (MDS) assessment for 1 of 1 resident (R5) who was reported to be receiving insulin.

Inspectors wroteBased on interview and document review the facility failed to develop a care plan for 1 of 13 residents (R15) who was identified as being at risk for falls upon admission.

Inspectors wroteBased on the facility failed to revise the care plans for 2 of 12 sampled residents (one who was to be receiving comfort cares (R15), and one (R2) who developed a pressure ulcer).

Inspectors wroteBased on interview and document review, the facility failed to complete a comprehensive assessment for continued use of antibiotics for 2 of 3 (R19 and R22) sampled residents reviewed for antibiotic stewardship.

Inspectors wroteBased on observation and interview, the facility failed to ensure 1 of 1 exhaust vent located above the gas stove was free from accumulation of dirt and grease that had the potential to contaminate food being prepared and served. This had the potential to affect all 28 residents who received food prepared in the facility kitchen.

Inspectors wroteBased on observation and interview the facility failed to avoid the potential risk of burns from 1 of 1 unattended Bunn brand coffee warmer used in the dining room.

Inspectors wroteR7's annual Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment without hallucinations or delusions. R7 had diagnoses of neurocognitive disorder with Lewy bodies, Parkinson's disease with dyskinesia, bipolar disorder, mild dementia, major depressive disorder, and anxiety disorder. R7's physicians orders indicated the following psychotropic medication orders: quetiapine dated 1/9/25 (an antipsychotic). Informed consents regarding risks versus benefits of these medications were not found in the resident record. During interview on 3/25/25 at 4:54 p.m., Director of Nursing (DON) stated she was unaware of the requirement, and this had not been completed. DON stated understanding of the importance of residents and their representatives being aware of the risks verses benefits of the psychotropic medications being prescribed. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure the use of appropriate personal protection equipment (PPE) was utilized during blood glucose testing, and subsequent insulin administration for 2 of 2 residents (R7 and R22). In addition, the facility failed to ensure mechanical lifts were regularly cleaned and/or disinfected between resident use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 1 resident (R5) had been appropriately assessed for wheelchair size by therapy.

Inspectors wroteBased on interview and document review, the facility failed to notify the resident and/or their responsible party, in writing, of the facility's bed hold policy, including potential costs included with the bed hold, at the time of transfer to the hospital for 4 of 4 residents (R1, R8, R15 and R18).

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure the hospice plan of care had been integrated with the facility care plan for 2 of 2 residents (R14 and R131) to delineate services provided between the facility and hospice.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all 25 nurse aides ((NA)-A, NA-B, NA-C, NA-D, NA-E, NA-F, NA-G, NA-H, NA-I, NA-J, NA-K, NA-L, NA-M, NA-N, NA-O, NA-P, NA-Q, NA-R, NA-S, NA-T, NA-U, NA-V, NA-W, NA-X, NA-Y and NA-Z), who bathed or had the potential to bathe residents were appropriately trained and deemed competent to manufacturer's instructions for the cleaning and disinfection of 1 of 1 whirlpool tub.

Inspectors wroteBased on interview and document review the facility failed to implement 1 of 1 facility assessment protocol related to ensuring staff competencies were identified and completed respective to staff duties performed.

Inspectors wroteBased on interview and document review, the facility failed to ensure data submitted to 1 of 1 Quality Assurance 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 28 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 28 residents.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure staff followed the facility protocols to verify controlled medication count to prevent potential diversion.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 2 of 2 observed nurse aides (NA) (NA-B and NA-C) appropriately cleaned and disinfected 1 of 1 whirlpool tub according to manufacturer's guidelines and use personal protective equipment (gown an gloves) (PPE) while cleaning and disinfecting the whirlpool tub. This affected 2 of 2 current residents (R3 and R11) who utilized the whirlpool tub for bathing.