Parkway Place

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (CR #1) of three residents reviewed for accidents, hazards, and supervision. The facility failed to ensure CNA G did not leave CR #1 unattended on the commode while she went and called LVN M to come and assess CR #1's foley because he was pulling on the foley and had asked CNA G to remove the foley, and he was bleeding from the penial area. This failure increased the risk of injury, hospitalization, and death for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #28) of 6 residents reviewed for medication administration. The facility failed on -Medication Aide A failed to administer Resident #28 acetaminophen (Tylenol) extra strength 500mg every 12hours by mouth (8:00AM & 8:00PM) as ordered by the physician and at the scheduled time. Resident #28's medication was provided 1 hour and 53 minutes late on 05/28/2025. This failure placed resident at risk for unwanted pain and decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for two Residents (Resident #7 and Resident #28, and Resident #29), of 6 residents observed for care and procedures, in that: The facility failed when MA A failed to sanitize a blood pressure machine prior to and after taking Resident #7, Resident #28, and Resident #29's blood pressure on 05/28/2025. This failure placed residents at risk for cross contamination and infections.

Inspectors wroteBased on observation, interviews, and records reviewed, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 3 (Resident #1, Resident #2, and Resident #3) of 6 residents reviewed for accidents. -CNA B performed a two person transfer alone using a sit to stand lift instead of a full Hoyer lift when resident was unable to stand on 08/06/24. Resident #1 suffered a right transverse impacted fracture of the proximal humeral metaphysis (broken upper arm) and a right periprosthetic fracture (broken knee bone). -Observation of a Hoyer lift transfer revealed the Hoyer pad/sling was not properly placed under Resident #3's bottom. -CNAs E and F performed a sit to stand transfer for Resident #2 using a cracked footrest and failed to use the calve strap for safety on 08/30/24. [...]

Inspectors wroteBased on interviews, observation, and records reviewed, the facility failed to immediately consult with the resident's physician and notify the resident representative when there was a significant change in the resident's condition or need to alter treatment significantly for 1 of (Resident 1) of 9 residents reviewed for notify of changes. -LVN A failed to report Resident #1's change in condition to the MD/NP after she fell on [DATE] when CNA B performed a two person transfer alone. Resident #1 suffered a right transverse impacted fracture of the proximal humeral metaphysis (broken upper arm) and a right periprosthetic fracture (broken knee bone). On 09/21/24 an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interviews, observations, and records reviewed, the facility failed to obtain radiology or other diagnostic services to meet the needs of its residents in a timely manner for 1 (Resident #1) of 7 residents reviewed for radiology services. -The facility failed to obtain radiology services for Resident #1 in a timely manner after she fell on [DATE] and bruises appeared on 08/07/24. Resident #1 suffered a right transverse impacted fracture of the proximal humeral metaphysis (broken upper arm) and a right periprosthetic fracture (broken knee bone). On 09/21/24 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/24/24, the facility remained out of compliance at a severity level of no actual harm with potential for minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 residents (Resident #21, and Resident #135) reviewed for incontinent care. 1. The facility failed to ensure Wound Care nurse did not place Resident #21's foley bag on the bed during foley care. 2. The facility failed to ensure Resident # 135's foley bag, privacy bag and tubing were not lying on the floor. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments and accessed only by authorized personnel for 3 of 6 residents (Resident #22, Resident #3 and Resident#136) reviewed for medication storage in that: Resident #22 had a tube of antifungal cream on the bed side table and did not have an order to self-administer. The facility failed to ensure MA J did not leave Resident #3's rivastigmine 9.5 mg transdermal patch on top of the medication cart unattended. The facility failed to ensure RN G did not leave a bottle of Lantus insulin on top of the nurse's cart unattended. These failures could place residents at risk of loss of their medications, inadequate therapeutic outcomes, or decline in health.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure expired foods were not discarded. 2. The facility failed to ensure foods were labeled and dated. 3. The Facility failed to ensure food was safely stored in designated areas at all times. These failures could place residents who ate food from the kitchen and place them at risk of food borne illness and disease. Findings Included: Observation of the facility's kitchen on 04/03/24 at 8:15 AM revealed the following leftover foods found in the walk in refrigerator was not discarded prior to the use by date. 1. A Plastic Container of Pot Roast was dated 3/27/24 with use by date 4/01/24 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Food and nutrition services. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 3 of 5 residents (Resident #21, Resident #153, and Resident #24) observed for infection control. 1. The facility failed to ensure Wound Care Nurse did not place Resident #21's foley bag on the bed during foley care. 2. The facility failed to ensure Wound care Nurse followed infection control procedure while providing wound care for Resident #21. 3. The facility failed to ensure Resident # 135's foley bag, privacy bag and tubing from lying on the floor. 4. The facility failed to ensure CNA M followed proper infection control procedure while providing incontinent care for Resident # 24. These failures could place the residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7% based on 4 errors out of 27 opportunities, which involved 2 of 6 residents (Resident #3, and Resident #22) reviewed for medication errors in that: 1-MA J administered calcium 600 instead of calcium 600 with vitamin D3 600 mg-12.5 mcg to Resident # 3. 2-RN G left a substantial amount of metoprolol tartrate 25 mg tablet in the portion cup after medication was administrated through g tube to Resident #22. These failures could place residents at risk for increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food items that were opened were sealed, labeled and dated . 2. The facility failed to ensure expired foods were not stored with unexpired foods . 3. The facility failed to ensure equipment was cleaned . 4. The facility failed to ensure foods stored in the refrigerator were used by the used by dates. These failures could place residents at risk of food-borne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure residents the right to formulate an advance directive for 1 (Resident #138) of 16 residents reviewed for advance directives. Resident #138's electronic health record did not reflect her Out of Hospital Do Not Resuscitate (OOH-DNR) status. This failure could place residents at risk of not having their end of life wishes implemented or respected.

Inspectors wroteBased on interview and record review the facility failed to develop and implement person-centered care plans for each resident which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #22) of 8 residents reviewed for care plans. The facility failed to update Resident #22's care plan to reflect a fall and interventions that occurred on 3/5/23. This failure could place residents at risk of not receiving care based on identified needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #14) reviewed for incontinent care. CNA A failed to properly cleanse Resident #14 during incontinent care. CNA A failed to change gloves and perform hand sanitization during incontinent care for Resident #14. This failure could place residents at risk for urinary tract infections (UTI), urethral erosions (tearing of the urethra), discomfort, skin breakdown, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of 1 (Resident #28) of 6 residents reviewed for pharmacy services. LVN D did not administer Lisinopril 10 mg (a high blood pressure medication) to Resident #28 as ordered by the physician. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 resident (Resident #14) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene between dirty and clean care while providing incontinent care to Resident #14. These failures could place residents who require wound care and incontinent care at an increased risk for infection, decline in health and hospitalization.