Parkwood Health & Rehabilitation

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure drug records were in order and an account of all drugs was maintained and periodically reconciled for 4 out of 12 residents who received narcotic medications, out of the total sample of 23 residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure all medications and wound care products used in the facility were stored and labeled in accordance with professional standards, with the potential to affect 25 out of 25 residents receiving wound care.

Inspectors wroteBased on interview, record review and review of facility policy and procedure, the facility failed to ensure resident participation in the development of the comprehensive care plan for 3 of 8 residents (Resident (R)16, R94, and R72) out of the total sample of 23 residents.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, the facility failed to ensure resident assessments accurately reflected a resident's status for 1 of 3 residents reviewed for MDS accuracy out of the total sample of 23 residents, (Resident (R)16).

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision for one of 31 sampled residents (Resident (R) 13). The facility implemented their procedures and a correction plan, and after review of records and interviews it was determined the facility implemented their correction plan as alleged with a completion date of 05/07/2025, prior to survey entry.

Inspectors wroteBased on observation, interview, record review, and review of facility policy and food storage reference material, the facility failed to store food in accordance with facility policy and accepted standards of food service/management. Foods were not dated and/or labeled when opened. The deficient practice had the potential to affect 85 of 89 residents who consumed food stored and /or used in this kitchen.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to provide a clean and homelike environment for residents. The bathrooms and hallways had a strong odor of urine and were not clean, floors were soiled, sticky, stained and/or rusted. The failure to maintain a clean, homelike environment had the potential to affect Resident (R) 31, R44, and R75, as well as, all other residents residing on two of the three facility halls, with 15 resident rooms on each hallway.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to implement an infection prevention and control program designed to prevent the development and transmission of communicable disease and infections for two of 76 sampled residents (Resident (R)11 and R35). Staff failed to perform hand hygiene when indicated, as well as failed to handle and dispose of a soiled dressing in a manner to prevent the possible spread of infection. In addition, the facility failed to ensure that required Personal Protective Equipment (PPE) was readily available and worn by staff when providing care for a resident who was on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on interview, record review and review of the facility policy, the facility failed to develop a comprehensive person-centered care plan for one (Resident (R) 85) of 76 sampled residents, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. The Care Area Assessments (CAA) that triggered for care planning, as well as, other areas such as medical needs, goals, and discharge planning, were not included in R85's comprehensive care plan by the required completion date (no later than 21 days from admission).

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to provide the necessary care and services to ensure that two (Resident (R) 49 and R 58) of two sampled residents reviewed for activities of daily living/communication did not decline in their ability to communicate. The residents were not provided communication tools in accordance with their plans of care.

Inspectors wroteBased on interview, record review, review of facility policy, and review of a facility investigation, the facility failed to have an effective system in place to ensure resident safety for one (Resident (R) 140) of two sampled residents reviewed for elopements. On 09/04/2022, R140 eloped from the facility unescorted and unsupervised, and required police intervention to locate the resident and return him to the facility. On 06/28/2024, the Administrator and Director of Nursing (DON) were provided a copy of the CMS IJ Template and notified that the failure to ensure residents were provided supervision and protected from further elopement, constituted immediate jeopardy at F 689. The Immediate Jeopardy (IJ) at F 689 also constituted Substandard Quality of Care at 42 CFR 483.25. The IJ was determined to exist on 09/04/2022 when the facility discovered R140 had eloped from the building. [...]

Inspectors wroteThe facility implemented the following actions to remove Immediate Jeopardy: 1. On 03/26/19 at approximately 9:45 PM, a law enforcement officer escorted Certified Nursing Assistant (CNA) #13 out of the building and off the property. 2. On 03/26/19, the Administrator informed staff to immediately contact the police if CNA #13 attempted to reenter again, after CNA #13 had re-entered the facility to retrieve alleged belongings and left. 3. On 03/26/19, Administrator suspended CNA #13, pending investigation, and then subsequently terminated her position on 04/02/19. 4. On 03/27/19, the Regional Director of Operations (RDO) interviewed Resident #52 related to possible safety concerns when CNA #13 returned to the facility and entered the resident's room to retrieve personal belongings, after local law enforcement had escorted her out of the facility on 03/26/19. 5. [...]

Inspectors wroteThe facility implemented the following actions to remove Immediate Jeopardy: 1. On 03/26/19 at approximately 9:45 PM, a law enforcement officer escorted Certified Nursing Assistant (CNA) #13 out of the building and off the property. 2. On 03/26/19, the Administrator informed staff to immediately contact the police if CNA #13 attempted to re-enter again, after CNA #13 had re-entered the facility to retrieve alleged belongings and left. 3. On 03/26/19, Administrator suspended CNA #13, pending investigation, and then subsequently terminated her position on 04/02/19. 4. On 03/27/19, the Regional Director of Operations (RDO) interviewed Resident #52 related to possible safety concerns when CNA #13 returned to the facility and entered the resident's room to retrieve personal belongings, after local law enforcement had escorted her out of the facility on 03/26/19. 5. [...]

Inspectors wroteThe facility implemented the following actions to remove Immediate Jeopardy: 1. On 03/26/19 at approximately 9:45 PM, a law enforcement officer escorted Certified Nursing Assistant (CNA) #13 out of the building and off the property. 2. On 03/26/19, the Administrator informed staff to immediately contact the police if CNA #13 attempted to re-enter again, after CNA #13 had re-entered the facility to retrieve alleged belongings and left. 3. On 03/26/19, Administrator suspended CNA #13, pending investigation, and then subsequently terminated her position on 04/02/19. 4. On 03/27/19, the Regional Director of Operations (RDO) interviewed Resident #52 related to possible safety concerns when CNA #13 returned to the facility and entered the resident's room to retrieve personal belongings, after local law enforcement had escorted her out of the facility on 03/26/19. 5. [...]

Inspectors wroteThe facility implemented the following actions to remove Immediate Jeopardy: 1. On 03/26/19 at approximately 9:45 PM, a law enforcement officer escorted Certified Nursing Assistant (CNA) #13 out of the building and off the property. 2. On 03/26/19, the Administrator informed staff to immediately contact the police if CNA #13 attempted to re-enter again, after CNA #13 had re-entered the facility to retrieve alleged belongings and left. 3. On 03/26/19, Administrator suspended CNA #13, pending investigation, and then subsequently terminated her position on 04/02/19. 4. On 03/27/19, the Regional Director of Operations (RDO) interviewed Resident #52 related to possible safety concerns when CNA #13 returned to the facility and entered the resident's room to retrieve personal belongings, after local law enforcement had escorted her out of the facility on 03/26/19. 5. [...]

Inspectors wrote4. Review of Resident #23's clinical record revealed the facility admitted the resident on 02/12/19, with diagnoses of Generalized Muscle Weakness, Unspecified Macular Degeneration, Dementia, and Abnormalities of Gait and Mobility. Review of Resident #23's admission MDS, dated [DATE], revealed the facility assessed the resident required extensive assistance to complete transfers and for locomotion. The facility conducted a BIMS exam with a score of four (4) out of fifteen (15) and determined the resident was not interviewable. Review of Resident #23's Care Plan, dated 02/12/19, revealed the resident was at risk for falls related to weakness, Dementia, history of falls, and psychoactive medications. Interventions included all staff was to be sure the resident's call light was within reach and encourage the resident to use it for assistance. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to prevent the development of a pressure ulcer and promote healing for one (1) of forty-four (44) residents, Resident #22. The facility re-admitted Resident #22 on 01/12/19 with no pressure ulcers and assessed the resident to be at risk for skin breakdown. On 02/04/19, the resident developed a pressure ulcer to the left heel and the facility put treatments in place, which included elevating the heel with a heel lift boot. However, multiple observations during survey revealed the resident in bed without the heel boot on and his/her heels in contact with the mattress. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain resident dignity for one (1) of forty-four (44) residents, Resident #70. Observation revealed staff stood over Resident #70 while assisting the resident with his/her lunch meal.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of one (1) of forty-four (44) residents, Resident #26. Review of a Significant Change MDS, dated [DATE], revealed Resident #26 was coded for taking anti-coagulant medication; however, review of the resident's physician orders for February 2019 and March 2019 revealed the resident was not prescribed an anti-coagulant.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure one (1) of forty-four (44) residents, Resident #54, received the necessary restorative services to prevent a decline in mobility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an environment free of accidents and hazards for two (2) of forty-four (44) residents, Residents #23 and #95. Resident #23 was at risk for falls and required assistance to transfer and for locomotion. Observation revealed Staff did not place Resident #23's call light within the resident's reach in order for the resident to ask for staff assistance if needed. In addition, Resident #95's bed controller had exposed wiring on the cord.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of forty-four (44) residents was free from unnecessary medication, Resident #97.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to maintain safe and secure storage of medications in one (1) of two (2) medication rooms. Observation revealed unlicensed personnel in the North Hall medication room unsupervised. In addition, staff stored personal items, such as purses, in the medication room.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to maintain an effective infection prevention and control program related to identification of communicable diseases for residents and staff. Record reviews revealed the facility did not complete Tuberculosis Risk Assessments for five (5) of forty-four (44) residents, Residents #26, #50, #56, #61, and #90. In addition, review of personnel records revealed the facility did not administer Tuberculosis Skin Test (TST), nor complete Tuberculosis Risk Assessments, for six (6) staff members.

Inspectors wroteBased on interview and record review, it was determined the facility failed to post accurate staffing information on a daily basis.