Signature Healthcare at Parkwood

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician's order to obtain weekly weights were followed for 2 of 3 residents reviewed for quality of care. (Resident B and J)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives were invited to participate in care plan meetings for 4 of 4 residents reviewed for care plan conferences. (Residents 36, 64, 75 and 58)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who resided on the locked memory care unit was provided cognitively stimulating activities according to the plan of care for 1 of 4 residents reviewed for activities. (Resident 20)

Inspectors wrote2. The clinical record for Resident 50 was reviewed on 2/14/25 at 11:51 a.m. The diagnoses included, but were not limited to, type 2 diabetes, type 2 diabetes with ketoacidosis (a complication of diabetes), and acute kidney failure. A care plan, dated 8/7/24, indicated Resident 50 had diabetes. Interventions included, but were not limited to, to administer medications according to the physician's order. A physician's order indicated to notify the physician if Resident 50's blood glucose reading was less than 150. The Medication Administration Record (MAR) indicated Resident 50's blood glucose reading was below 150, 14 times in January 2025 and 14 times in February 2025. There was no documentation in Resident 50's medical record to indicate the physician was notified of the blood glucose readings below 150 according to the physician's order. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a consent for an Influenza vaccination was obtained prior to administration and to ensure Influenza and Pneumococcal vaccines were offered for 3 of 5 residents reviewed for immunizations. (Resident 53, 139 and 11)

Inspectors wroteBased on interview and record review, the facility failed to ensure COVID-19 vaccinations were offered to residents for 3 of 5 residents reviewed for immunizations. (Resident 53, 139 and 23)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure effective person-centered dementia care was provided to prevent residents on the locked dementia unit from wandering into the room of a resident with known aggressive, impulsive, and sexually inappropriate behaviors and no diagnosis of dementia for 4 of 4 residents reviewed on the dementia care unit. (Residents D, C, B and E)

Inspectors wroteBased on interview and record review, the facility failed to accept a cognitively impaired resident back to the facility following a transfer to the hospital for evaluation and treatment and failed to adequately document the reason for his discharge from the facility in his record for 1 of 3 residents reviewed for appropriate discharge (Resident B).

Inspectors wroteBased on interview and record review, the facility failed to follow up with Psychiatric services to get Psychiatric care prior to the resident eloping from the facility and failed to adequately document the elopement in the resident's record for 1 of 3 residents reviewed for Psychiatric services (Resident B).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a cognitively impaired and dependent resident was safe from an injury of unknown origin (Resident F), failed to ensure a resident did not have vaping materials in the room (Resident 72) and failed to prevent recurring falls for a resident who was identified as a high risk to experience falls (Resident H) for 3 of 3 residents reviewed for accidents. The deficient practice resulted in Resident F sustaining a left arm fracture.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff treated residents with respect and dignity and to ensure a resident was provided clothing for 4 of 4 residents reviewed for respect and dignity. (Residents J, D, K, and C)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff identified low dishwasher temperatures to ensure the dishwasher was cycling at the recommended temperature for 1 of 1 dishwasher reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) was completed when a new diagnosis of psychosis was added along with an antipsychotic medication and to implement the PASARR recommendations for a resident with a known mental health condition for 2 of 3 residents reviewed for PASARR. (Resident 36 and K)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who resided on the dementia unit was provided cognitively stimulating activities for 1 of 3 residents reviewed for activities. (Resident K)

Inspectors wroteBased on observation, interview and record review, the facility failed to provide incontinence care for 1 of 3 residents reviewed for activity of daily living (ADL) care. (Resident 47)

Inspectors wroteBased on record review and interview, the facility failed to recognize significant weight changes, complete re-weights, implement timely interventions, and to make notifications to the physician and resident representative for 3 of 5 residents reviewed for nutrition. (Resident F, L and J)

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment, interventions, and psychiatric services for a resident diagnosed with a mental disorder for 1 of 5 residents reviewed for behavioral-emotional health. (Resident K)

Inspectors wrote3. The clinical record for Resident 72 was reviewed on 2/1/24 at 1:28 p.m. The diagnoses included, but were not limited to, brain injury without loss of consciousness and cognitive communication deficit. A physician's order, dated 1/5/24, indicated the resident was on olanzapine (an antipsychotic medication)15 mg once a day. This was a new antipsychotic medication the resident was put on. A physician's order, dated 1/8/24, indicated to complete an abnormal involuntary movement scale (AIMS) assessment quarterly once a day on the 5th of January, April, July, and October. An admission observation report, with a scheduled date of 1/5/24 and a due date of 1/7/24, indicated the AIMS assessment was completed on 2/5/24 at 4:45 p.m. The AIMS assessment was not completed until 2/5/24 with a due date of 1/7/24. [...]

Inspectors wrote2. During an observation of the Rosewood North medication cart, on 2/5/24 at 9:16 a.m., with QMA 6, the following was observed: a. On the back of the narcotic card of hydrocodone-acetaminophen (a controlled pain medication) 5/325 milligrams(mg) tablets for Resident 70, there was an opening in slot 4. b. On the back of the narcotic card of oxycodone/acetaminophen (a controlled pain medication) 10-325 mg tablets for Resident 17, there was an opening in slot 7. The clinical record for Resident 70 was reviewed on 2/5/24 at 10:00 a.m. The diagnoses included, but were not limited to, cognitive communication deficit, mood disorder due to known physiological condition with depressive features, bipolar disorder, and anxiety disorder. A physician's order, dated 1/22/24, indicated to give hydrocodone-acetaminophen 5/325 mg 1 tablet every 12 hours when needed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure toilet bolts were covered, walls were free from marks, scratches, peeled paint, gouges, and paint chips, cabinets were free from dirty towels and common area ceilings were free from black spots and uneven areas for 17 of 74 rooms and common area reviewed for environment. (Rooms 3, 4, 5, 6, 7, 9, 11, 14, 17, 18, 27, 28, 30, 58, 60, 71, 72)

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party/Power of Attorney (POA) when a new order for an antipsychotic was received and administered and failed to notify the physician when medications were unavailable for administration for 2 of 3 residents reviewed for notification of changes. (Resident B and C)