Parsons Hill Rehabilitation & Health Care Center

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose treatment orders included daily wound care, the facility failed to ensure they maintained a complete and accurate medical record, when nursing documentation related to his/her wound care treatments on multiple days in the month of June 2026, was found to be incomplete and/or inaccurate.

Inspectors wroteBased on record review, and interview, the facility failed to ensure four Residents (#7, #14, #1, and #71) out of a total sample of 29 residents were seen by a Physician at the required regulatory frequency for Physician visits. Specifically, the facility failed to ensure that Residents #7, #14, #1, and #71 were seen by a Physician for alternating visits with the Nurse Practitioner (NP) every 60 days as required, after the Residents were in the facility for 90 days.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that one Resident (#3) of five applicable residents sampled for unnecessary medications, out of a total sample of 29 residents, was free from unnecessary psychotropic (medication that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, perception and behaviors) medications. Specifically, for Resident #3, the facility failed to monitor for potential side effects and evaluate the Resident's response to Seroquel (Quetiapine - antipsychotic medication), Klonopin (Clonazepam - benzodiazepam medication), Ativan (Lorazepam - benzodiazepam medication), and Zoloft (Sertraline - antidepressant medication) medications, placing the Resident at risk for unidentified medication side effects and/or complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#147), of one applicable resident receiving dialysis (process that filters wastes, salts and fluid from your blood when the kidneys are unable to work adequately) services, out of a total sample of 29 residents. Specifically, for Resident #147, the facility failed to ensure:-medications were administered timely when the Resident attended regularly scheduled dialysis treatments. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain accurate records of controlled substances (drugs or chemicals that the government regulates for its manufacture, possession, and use, that are classified into schedules based on their potential for abuse) for one Controlled Substance Book on the Greendale Unit, out of three controlled substance books reviewed. Specifically, for the Greendale Unit, the facility failed to maintain a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation in the Controlled Substance Book (Narcotic Book).

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were stored in accordance with accepted professional standards of practice, as required, for one (Greendale Unit) medication cart, out of three medication carts reviewed. Specifically, for the Greendale Unit medication cart, the facility failed to properly secure medications and ensure the medication cart was sanitary and free of debris.

Inspectors wroteBased on observation and interviews, the facility failed to keep confidential information contained in the resident's record secure, in accordance with accepted professional standards and practice for one (Greendale Unit) medication cart computer screen, out of three medication cart computer screens reviewed. Specifically, for the Greendale Unit medication cart computer screen, the facility failed to properly secure the computer screen containing confidential resident specific medication administration information when the computer screen was left unlocked and unattended, leaving the information readily viewed by unauthorized persons.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement infection control practices to prevent transmission of infections for one Residents (#136) out of a total sample of 29 residents. Specifically, for Resident #136, the facility failed to ensure that staff implemented Enhanced Barrier Precautions (EBP- the use of protective equipment such as gowns and gloves to prevent the spread infection from one person to another) during high contact care activities for the Resident, placing the Resident, other residents, and staff at risk for the spread of infection.

Inspectors wroteBased on record review, and interview, the facility failed to provide written notification of a hospital transfer to the Resident's Responsible Party for one Resident (#2) out three closed records sampled. Specifically, for Resident #2, the facility failed to provide written notice of transfer to the Resident's Responsible Party when the Resident was emergently transferred to the hospital for respiratory distress.

Inspectors wroteBased on records reviewed and interviews, for three of four sampled residents (Resident #1, Resident #2, and Resident #4), the Facility failed to ensure that prior to the time of their discharge from the facility, that the Residents were provided with a Notice of Intent to Discharge which included the necessary information to appeal, and that a copy of the Notice of Intent to Discharge was sent to the Office of the State Long-Term Care Ombudsman.

Inspectors wroteBased on records reviewed and interviews, for three of three sampled residents (Resident #1, #2, and #3), as well as interviews with several non-sampled residents, the Facility failed to ensure the residents were treated in a dignified and respectful manner by a staff member, when all of the residents reported that Certified Nurse Aide (CNA) #1's behavior toward them was rude and aggressive, that CNA #1 yelled at and could be mean to them, and had stopped asking CNA #1 for assistance in order to avoid having any interaction with her.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were implemented as required for three Residents (#116, #122, and #49), out of a total sample of 29 residents. Specifically, the facility failed to: 1. For Resident #116, act upon the Consultant Pharmacist recommendations dated 10/19/24 and 11/23/24, to discontinue a Multivitamin and Calcium tablets to reduce polypharmacy (use of multiple medications at once, often exceeding what's clinically necessary) when the recommendations were reviewed and agreed upon by the Physician. 2. [...]

Inspectors wroteBased on observation, and interview, the facility failed to adhere to infection control standards of practice, increasing the risk of contamination and the spread of infection to other residents within the facility. Specifically, the facility failed to ensure that housekeeping staff on the Greendale Unit adhered to appropriate Personal Protective Equipment (PPE) use and hand hygiene when cleaning resident rooms.

Inspectors wroteBased on observation, and interview, the facility failed to implement an effective pest control program on three Units (Tatnuck, Greendale, and [NAME]) out of five units observed, and impacting nine Residents (#42, #97, #144, #53, #21, #85, #49, #119 and #63) on the three Units. Specifically, the facility failed to implement effective pest control measures when: -live mice were observed in Resident's rooms by the survey team for the duration of the survey. -Exterminator services were suspended when bi-weekly Exterminator visits were indicated in the facility's pest control plan and the pest control issues related to mice in the facility was not resolved. -Residents in Resident Council meetings reported ongoing mice activity.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that residents and/or their representatives were informed and given necessary information to make health care decisions including the risks and benefits of psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications prior to their use for one Resident (#205) out of a total sample of 29 residents. Specifically, for Resident #205, the facility failed to obtain informed consent from the Resident with notification of the risks and benefits for the use of Clonidine (antihypertensive medication that can also be prescribed for anxiety) prior to administering the medication to the Resident.

Inspectors wroteBased on observation, and interview, the facility failed to provide a safe and homelike environment for one Resident (#3) out of a total sample of 29 residents, and for residents on one Unit (Burncoat) out of five Units. Specifically, the facility failed to: -repair a hole located in the wall behind the headboard of Resident #3's bed. -enclose exposed pipes (from a water fountain removal) protruding from a wall in a hallway on the Burncoat unit, placing residents at potential risk of injury.

Inspectors wroteBased on record review, and interview, the facility failed to coordinate vision care services for one Resident (#129) out of a total sample of 29 residents. Specifically, for Resident #129, the facility failed to schedule vision care appointments and ensure that the Resident was seen and received appropriate treatment to maintain vision abilities, when the Resident consented to and requested vision care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services relative to enteral feeding (also known as tube feeding, is the delivery of nutrients directly into the stomach), for one Resident (#116), out of a total sample of 29 residents. Specifically, for Resident #116, the facility failed to label and date enteral feeds and fluids being administered to the Resident via Gastrostomy Tube (G-tube - tube placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) as required, to ensure the enteral nutrition administration was consistent with Physician orders and that the product had not exceeded the expiration date.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#91), out of a total sample of 29 residents. Specifically, for Resident #91, the facility failed to ensure that the oxygen concentrator was set at 2 liters per minute (LPM) as ordered by the Physician, when the Resident was observed with the oxygen concentrator set at 1.5 LPM.

Inspectors wroteBased on record review, and interview, the facility failed to provide care and services consistent with professional standards of practice related to renal dialysis (procedure to remove waste products and excess fluid from the body when the kidneys stop functioning properly) for two Residents (#93 and #147), out of a total sample of 29 residents. Specifically, the facility failed to communicate and maintain ongoing documentation with the dialysis center to ensure that the dialysis center and the facility received the most current information pertaining to Resident's #93 and #147.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC: notice issued to a resident who is receiving benefits under Medicare Part A when all covered services end) was accurately issued for one Resident (#130) out of three applicable residents, out of a total sample of 29 residents. Specifically, for Resident #130, the facility failed to ensure that a paper copy of the NOMNC was provided to the Resident's responsible party as required.

Inspectors wroteBased on interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) Assessments for two Residents (#49 and #67) out of a total sample of 29 Residents. Specifically: 1. For Resident #49, the facility coded the Resident as utilizing an external catheter during the observation period for the MDS assessment, when he/she did not utilize an external catheter. 2. For Resident #67, the facility failed to accurately code that the Resident was utilizing an antidepressant medication (Trazodone) during the observation period for the MDS assessment.

Inspectors wroteBased on records reviewed and interviews, the Facility, (who had an in-house census of 148 residents) failed to ensure that the Director of Nurses (DON) did not serve as a charge nurse on a unit, when their daily occupancy rate was greater than 60 residents.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who's Comprehensive Care Plan and Hospital Discharge Summary indicated he/she required supervision with eating, the Facility failed to ensure they maintained a complete and accurate medical record when Certified Nurse Aides (CNAs) documented that Resident #1 was independent for eating and his/her CNA Care Card (used by the CNAs to determine individual care needs) was incomplete.

Inspectors wroteBased on interview and record review, the facility failed to provide coverage as required by a Registered Nurse (RN) for at least eight consecutive hours a day for seven days a week. Specifically, the facility was unable to provide evidence that a Registered Nurse (RN) was scheduled and worked for a minimum of eight hours during the 24-hour period on Monday 1/1/2024, when no staffing waivers were in place.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately completed to reflect the status for six Residents (#97, #141, #39, #40, #24 and #13), in a total sample of 31 residents. Specifically, the facility staff failed to accurately reflect on the MDS assessment that: 1. For Resident #97, that he/she was not receiving dialysis services (a treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) while residing in the facility. 2. For Resident #141, to document, Not Rated instead of continence (ability to control bladder movements), when the Resident had a foley catheter (a tube inserted to drain urine from the bladder). 3. For Resident #39, that he/she did not have a diagnosis of Pneumonia and Septicemia during the MDS assessment time frame 4. [...]

Inspectors wroteBased on interview, policy and record review, the facility failed to ensure that three licensed nursing staff (Unit Manager #2, Nurse #5 and Nurse #6), out of a sample of five licensed nursing staff, completed the specific competencies and skill sets necessary to care for residents' needs as identified for one Resident (#102). Specifically, the facility failed to ensure: 1. that nursing staff competencies for three licensed nursing staff (Unit Manager [UM] #2, Nurse #5 and Nurse #6) were completed as necessary to provide safe nursing and related services for facility residents. 2. that Resident #102 could receive dialysis catheter care from licensed nursing staff who were able to demonstrate that they possess the competency to use emergency dialysis equipment in a manner that accomplishes their purpose.

Inspectors wroteBased on observation, interview, and National Standards reviewed, the facility failed to provide a safe, sanitary environment for all residents, staff, and visitors and failed to control the source of potential infection on one Unit (Tatnuck) out of five units observed and the rooms of three Residents (#115, #12, and #248). Specifically, the facility failed to: 1. Adequately clean Resident's #115, #12, and #248 rooms of rodent droppings when rodent infestation in the rooms was well known to the facility. 2. Implement cleaning techniques for rodent droppings according to National Standards in order to reduce the risk of infection for all individuals on the Unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Resident (#40) out of a total sample of 31 residents was treated with dignity and respect. Specifically, the facility staff failed to intervene as needed when residents on the Tatnuck Unit directed yelling, using profane language, and name-calling at Resident #40.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to prohibit and prevent abuse and retaliation following the reporting of an alleged violation to law enforcement for two Residents (#77 and #248) . Specifically, the facility staff failed to intervene when Resident #248 used verbal threats and threatening physical gestures towards Resident #77, after Resident #77 filed charges with law enforcement against Resident #248, relative to a previous physical altercation between the two Residents that resulted in right eye injury to Resident #77.

Inspectors wroteBased on interview and record review, the facility failed to re-submit a Level 1 Preadmission Screening and Resident Review (PASARR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that: 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability, 2) be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting], and 3) receive the services they need in those settings) when it was identified that one Resident (#15) out of a total sample of 31 residents, had a serious mental illness (SMI).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely development and implementation of care plans relative to fall prevention and trauma informed care for two Residents (#66 and #28) out of a total sample of 31 residents. Specifically, the facility staff failed: 1. For Resident #66, to develop a fall prevention care plan when the Resident had been identified on admission to the facility, on a fall risk assessment, as being at risk for falls, and the Resident also sustained two separate falls in the facility. 2. For Resident #28, to develop and implement a care plan for the Resident who had a known history of trauma, and account for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities as scheduled, on the Tatnuck Unit and to meet the needs of three Residents (#12, #40, and #248), in a total sample of 31 residents, based on their comprehensive assessments and preferences. Specifically, the facility failed to: 1. Provide an activity to Residents on the Tatnuck Unit during the time an activity was scheduled to occur. 2. Alert Residents #12, #40, and #248 of a change in the activity schedule from a group discussion activity to a food social group activity. 3. Invite Residents #12, #40, and #248 to participate in a food social group activity when the Residents had preferences for food related activities.

Inspectors wroteBased on record review and interview, the facility failed to provide proper assistive devices to maintain hearing abilities for one Resident (#28) out of a total sample of 31 Residents. Specifically, for Resident #28, the facility failed to follow-up on an Audiology recommendation for hearing aids.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate nutritional care and services for one Resident (#79), out of a total sample of 31 residents. Specifically, the facility staff failed to identify and address an unplanned significant weight loss for Resident #79 when the Resident had been identified as being at risk for nutritional decline.

Inspectors wroteBased on interview, policy and record review, the facility failed to ensure that one Resident (#102) out of a total sample of 31 Residents, received dialysis care consistent with professional standards of practice. Specifically, the facility failed to: 1. monitor and track the Resident's actual fluid intake as ordered. 2. to provide bedside equipment and supplies necessary to manage a medical emergency for a hemodialysis (machine that filters waste, salt and fluid from the blood when the kidneys can no longer function) access site.

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that performance reviews were completed every 12 months and regular in-service education was provided based on the outcome of the reviews, for two Certified Nurses Aides (CNAs #6 and #7) out of a sample of three CNAs. Specifically, the facility failed to ensure that expectations, individual performance, and training requirements were communicated to CNA #6 and CNA #7 through the annual performance appraisal process as required. Findings Include: Review of the Facility Assessment, dated November 2023, indicated: -Staff Training/Education included the following: >Required in-service training for nurse aides. >In-service training must address areas of weakness as determined in Nurse Aides' performance reviews and facility assessment and may address the special needs of residents as determined by facility staff. [...]

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to meet the nutritional needs for one resident (Resident #348) out of a total sample of 31 residents. Specifically, the facility staff failed to communicate and implement the Registered Dietitian (RD) recommendations to ensure that additional sandwiches were added to Resident #348's meal trays for improved nutritional intake and weight gain.

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to maintain accurate medical records to reflect the status of the residents for two Residents (#130 and #141) out of a total sample of 31 residents. Specifically, the facility staff completed the following inaccurate documentation on the Treatment Administration Record (TAR): 1. For Resident #130, that his/her oxygen (O2) tubing had been changed. 2. For Resident # 141, that his/her foley catheter (a thin flexible tube placed through the urethra that carries urine from the bladder to outside of the body) had been changed every night shift.

Inspectors wroteBased on interviews, records reviewed and policy review, the facility failed to ensure that the Pneumococcal Vaccine was offered to and/or administered to two Residents (#87 and #123) out of five applicable residents, in a total sample of 31 Residents, placing them at risk for contracting facility acquired Pneumonia.