Parkwood Health & Rehabilitation

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure drug records were in order and that an account of all narcotic medications was maintained and periodically reconciled for 4 of 12 residents receiving narcotic medications. Review of the facility’s medication administration policy showed staff were to follow the five rights of medication administration and confirm the right resident, medication, dose, route, and time at specific stages during administration, including before removing the medication from the container, matching the label to the medication order, after preparing the dose and before returning the medication to storage, and double checking that all information was accurate and properly documented. During observation of the medication cart on the Northeast hallway, the surveyor requested a narcotic reconciliation and an LPN performed the count with the surveyor verifying the narcotic binder. Several discrepancies were identified between the actual medication counts and the counts documented in the binder: one resident’s oxycodone card had 15 tablets while the form showed 16, another resident’s gabapentin bottle had 2 pills while the form showed 1, another resident’s oxycodone card had 16 tablets while the form showed 17, another resident’s lorazepam card had 15 tablets while the sheet showed 16, and another resident’s oxycodone/acetaminophen card had 20 tablets while the sheet showed 21. The LPN stated he had not documented the accurate narcotic count prior to administering the medication and said the count was documented after administration to reflect an accurate amount. The DON stated narcotics were to be compared to the binder daily and counted each time the cart key was passed, and the Administrator stated reconciling narcotic medications was to be done according to facility policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure medications and wound care products used in the facility were stored and labeled in accordance with professional standards. During observation of a wound care treatment cart located by the nurses' station, surveyors found multiple items that were expired, undated, opened, unsealed, or not stored in individualized bags, including Mupirocin ointment with no opened date, Fluorouracil 5% topical chemotherapy cream with no opened date and no cap, Medihoney ointment expired 09/01/2025, sterile water with no opened date or expiration date, Gentell collagen wound filler opened and undated, lemon glycerin swab sticks expired 06/2024, Skintegrity hydrogel impregnated 4x4 gauze expired 11/2022, Dakin's Solution quarter strength undated, Sani Cloth super large wipes expired 07/2025, Calcium Alginate dressing opened and undated, and Kerrafoam gentle border expired 10/01/2024. The facility policy required drugs and biologics to be stored in the packaging in which they were received, only the issuing pharmacy to transfer medications between containers, and discontinued, outdated, or deteriorated drugs or biologics to be returned to the dispensing pharmacy or destroyed. The WCN stated she was responsible for maintaining the treatment cart but was new to the position and was being trained by the former WCN. She said she did not know how often the cart should be checked for expired or improperly labeled items and stated the expired, undated, and improperly stored items were not acceptable. The former WCN, who was the MDS Nurse, stated it was the current WCN's duty to manage the cart and ensure medications and wound care products were labeled and stored unexpired according to professional standards, but she did not know how often the cart should be reviewed because she worked multiple roles and had not checked items she did not use. The DON stated treatment carts should be checked daily, kept clean and restocked, and that all residents' medications should be individually bagged, with expired items and opened products without dates removed; the Administrator stated nurses were responsible for maintaining the carts and ensuring items were not expired, opened without dates, or missing protective bags.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure resident participation in the development of the comprehensive care plan for 3 of 8 residents reviewed, including R16, R94, and R72. Facility policy required residents or their representatives to be given opportunities to participate in care planning and to be informed in a language they could understand about their total health status, including medical condition. The resident rights policy also stated residents had the right to be fully informed and participate in treatment, including in a language they could understand. For R16, the record showed admission on 09/16/2025, but there was no documented evidence in the comprehensive care plan, progress notes, or signature sheets showing the resident attended care plan meetings. The facility could not provide attendance signatures or proof that translation services were used to update the care plan. During interview, R16 stated she was from [NAME], had not received documents in Spanish, had not been given care plan documents in Spanish, and said the care team did not use the translation line to speak with her. She stated she had not attended any care plan meetings and communicated through Spanish-speaking staff or a translator app on her phone. For R94, the record showed admission on 12/18/2025, but there was no documented evidence that the resident attended care plan meetings, and the facility could not provide attendance documentation or proof of translation services for care plan updates. R94 stated the documents from the facility were written in English, he could not see well, and he had never been in a care plan meeting. For R72, the record showed admission on 05/25/2025, but there was no documented evidence in the care plan, progress notes, or signature sheets that the resident attended care plan meetings, and the facility could not provide attendance documentation or proof of translation services. R72’s representative stated she had not been consulted regarding the resident’s care plans, the documents she received were only in English, and staff did not use the translation line when communicating with her.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure resident assessments accurately reflected a resident’s status for 1 of 3 residents reviewed for MDS accuracy, Resident 16. Review of the CMS MDS 3.0 RAI Manual showed that ethnicity in A1005 should be obtained by asking the resident to select the category or categories that most closely correspond to their ethnicity, and medical record documentation should only be used if the resident is unable to respond and no family member, significant other, or guardian/legal representative provides a response. R16’s MDS assessment with an ARD of 12/22/2025 coded the resident’s ethnicity as Mexican, but the resident’s ethnicity was Cuban. During interview, R16 stated she came to the United States on a visa, had not received facility documents in Spanish, and said the care team did not use the translation phone to speak with her about her care or during assessments. She reported she had not attended any care plan meetings and relied on bilingual staff when available or a translator app on her phone to communicate. The admission coordinator stated demographic information in the EHR was pulled from hospital paperwork, and the MDS coordinator stated questions should be asked each time the assessment is performed and that assessments can be modified. The MDS coordinator later stated she used an old social services form to investigate the inaccurate ethnicity entry, and the DON stated he expected MDS nurses to review documentation and assess the resident in person.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with severe cognitive impairment and a history of psychiatric diagnoses, including bipolar disorder, paranoid schizophrenia, depression, and anxiety, was able to elope from the facility. The resident was assessed as having a severely impaired mental status and was care planned for behaviors such as wandering and attempting to leave the facility without a responsible escort. Despite these known risks, the facility's supervision and environmental safeguards were insufficient to prevent the resident from leaving the premises. On the day of the incident, the resident entered a vending machine room and subsequently exited the facility grounds through a courtyard gate. The gate was supposed to be secured, but the resident was able to manipulate the lock or exploit a gap in the fence, which was in poor condition at the time. Staff did not immediately notice the resident's absence; it was only after a period of time that a CNA discovered the resident was missing, prompting a search. The resident was eventually found outside a nearby store and returned to the facility without injury. Documentation revealed that prior to the incident, facility checks of entrances and exits, including the courtyard gate, were incomplete and not performed on weekends. The lock on the courtyard gate was found to be faulty, intermittently failing to latch, and the fence was described as being in very poor condition. Staff interviews confirmed that the resident was able to leave due to these environmental hazards and lapses in supervision, despite being identified as an elopement risk and having interventions in place on the care plan.

Penalty

Inspection fine: $10,209

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure resident safety, resulting in an elopement incident involving a resident identified as R140. On the night of the incident, the resident, who had a history of wandering and was equipped with a wander guard device, managed to exit the facility through a Southwest emergency door. The alarm on the door was triggered, but staff did not respond promptly, allowing the resident to leave the premises unsupervised. The resident was later found by police at a nearby convenience store and returned to the facility. The resident, R140, had been admitted with diagnoses including metabolic encephalopathy and alcohol dependence and was assessed as having a low risk for elopement initially. However, subsequent assessments indicated a high risk for wandering, and interventions such as a wander guard device and 15-minute location checks were implemented. Despite these measures, the resident was able to elope, indicating a failure in the facility's supervision and response systems. Staff interviews revealed that those present on the night of the elopement were either in resident rooms or on break and did not hear the alarm. The facility's investigation did not determine how long the alarm had been sounding before staff responded. The incident highlighted a lapse in the facility's ability to provide adequate supervision and timely response to alarms, which are critical in preventing elopements.

Removal Plan

• Resident no longer resides in the facility.
• A head-to-toe assessment was completed by a licensed nurse.
• The nurse practitioner was notified by a licensed nurse.
• SBAR was completed by a licensed nurse.
• An elopement assessment was completed by a licensed nurse.
• Ad Hoc QAPI meeting was held with the Administrator, Medical Director, Director of Nursing, Admissions Coordinator, Social Services Director, Dietary Manager, Human Resources Director, Housekeeping Director, Activities Director, and Therapy Director.
• One-on-one supervision was initiated, and the care plan was updated by the Interdisciplinary Team.
• The resident Representative was notified in person of the incident by a licensed nurse.
• Every shift behavior monitoring for exit-seeking behavior was continued per MAR and TAR until discharge.
• The resident had a wanderguard placement prior to the incident and was added to the care plan by a licensed nurse.
• Resident was seen by NP and/or physician.
• One-on-one monitoring was placed on orders.
• Resident was monitored by Social Services.
• Resident was reviewed by IDT for changes in behavior.
• An elopement assessment was completed for 81 residents by licensed nurses.
• Clinical and agency clinical staff were educated regarding elopement policy and elopement drill.
• As an ongoing practice, an elopement assessment will be completed upon admission, quarterly and as needed related to changes in the resident's exit-seeking behaviors.
• Discussion at clinical meetings of changes in behaviors with review of orders, review of MARs/TARs, care plan review, nurse' notes review, and reports by staff.
• Care plans will be updated as needed based on these reviews by the clinical leadership and IDT.
• Individual resident's care plans will be reviewed at least quarterly for needed updates as part of the resident's quarterly care plan conference.
• Resident reviewed by IDT for changes in behavior on multiple dates.
• One on Two monitoring and changed to every 15-minute checks with care plan revisions by licensed nurse, which remained until discharge.
• Ad Hoc QAPI meeting was held with the Administrator, Medical Director, and Interdisciplinary Team.
• Elopement Drills conducted daily by the Administrator, Director of Nursing, Housekeeping Supervisor, and/or the Maintenance Director.

Penalty

Inspection fine: $10,209

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store food in accordance with its policy and accepted standards of food service and management. During an observation of the kitchen, it was noted that several food items were not labeled or dated when opened. Specifically, a steam table pan in the walk-in refrigerator was covered in foil without a date or label, and a clear container in dry storage contained a white particle substance with no open date or label. Additionally, open packages of oatmeal, farina, elbow noodles, buttermilk mix, and brown sugar were found without open dates, along with five containers of seasonings in dry storage. Interviews with staff, including a Servesafe certified individual, two dietary aides, the Dietary Manager, and the Director of Nursing, confirmed that the facility's policy required all opened food items to be labeled with the current date and discarded if not labeled or dated. The staff acknowledged that food without a label or date should be thrown away due to the risk of spoilage and potential harm to residents. This deficiency had the potential to affect 85 of the 89 residents who consumed food stored and used in the kitchen.

Penalty

Inspection fine: $10,209

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a clean and homelike environment, as evidenced by strong urine odors and unclean conditions in various areas. Observations revealed that hallways and rooms, particularly those containing Rooms 106-116 and 121-135, had a persistent smell of urine. Floors were found to be dirty, with black marks, sticky substances, and dried urine puddles. Interviews with staff and residents confirmed these observations, with some staff acknowledging the odor while others denied it. The Director of Nursing attributed the smell to a resident's refusal to properly launder undergarments. Further deficiencies were noted in the cleanliness of individual resident bathrooms. One resident's bathroom had a brown substance, identified as stool, on the floor and wall, which had been present for several days despite daily cleaning claims by housekeeping staff. The resident expressed dissatisfaction with housekeeping services, citing language barriers with the staff. Another resident reported inadequate cleaning practices, such as failing to sweep before mopping and neglecting to clean vanities and mirrors. Interviews with CNAs and housekeeping staff revealed inconsistencies in cleaning routines and a lack of proper management oversight. Additionally, rust stains were observed on the floors and door jambs of several bathrooms, indicating a lack of maintenance. The Maintenance Director was unaware of these issues and mentioned that remodeling efforts were incomplete due to an external company's partial work. The DON confirmed that remodeling was ongoing, but there were no immediate plans to address the flooring issues. These observations and interviews highlight the facility's failure to provide a safe, sanitary, and homelike environment for its residents.

Penalty

Inspection fine: $10,209

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. For Resident 11, the Infection Control Registered Nurse (IC/RN) did not perform hand hygiene before and after a wound dressing change, placed personal items and clean dressings on potentially contaminated surfaces, and disposed of soiled dressings improperly. The IC/RN also failed to use a barrier when opening a clean dressing on the resident's bed, leading to potential contamination of the wound and surrounding areas. Despite these lapses, the IC/RN did not recognize any need for improvement in her practices. For Resident 35, who was on Enhanced Barrier Precautions (EBP) due to a colostomy, the facility did not ensure that Personal Protective Equipment (PPE) was readily available or used correctly by staff. During colostomy care, an LPN did not wear a gown and failed to perform hand hygiene after the procedure. Interviews with various staff members revealed a lack of understanding and awareness regarding EBP protocols, with some staff unaware of the need for gowns and gloves or the location of PPE supplies. The Director of Nursing (DON) and other administrative staff acknowledged the deficiencies in infection control practices and the lack of PPE availability. The DON confirmed that PPE should be accessible and that staff should be knowledgeable about EBP requirements. However, observations indicated that PPE was not consistently available in resident rooms or hallways, and staff education on EBP was insufficient, contributing to the facility's failure to prevent the spread of infections effectively.

Penalty

Inspection fine: $10,209

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R85, within the required timeframe. The care plan was supposed to be completed no later than 21 days from the resident's admission, but it was not finalized by the deadline. The comprehensive care plan was missing critical components, including measurable objectives and timeframes to address the resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, the care plan did not address areas triggered by the Care Area Assessments (CAA), such as communication, functional ability, fall risk, psychotropic drug use, urinary incontinence, and pressure ulcer/injury. Additionally, the care plan failed to address the resident's medical needs related to her tracheostomy/stoma and did not include goals or plans for discharge. The resident, R85, was admitted with diagnoses including adult failure to thrive, malfunction of tracheostomy stoma, and a history of blood clots. Despite having a baseline care plan completed within 48 hours of admission, the comprehensive care plan was not completed by the required date. Interviews with the resident revealed that she was unaware of her plan of care, the duration of her stay, or any discharge plans. Interviews with facility staff, including the Assistant MDS Coordinator and the MDS Coordinator, highlighted a lack of awareness and adherence to the required timeframes for completing comprehensive care plans. The MDS Coordinator acknowledged the oversight and took responsibility for the incomplete care plan.

Penalty

Inspection fine: $10,209

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary communication tools to two residents, leading to a decline in their ability to communicate. Resident 49, who was admitted with severe cognitive deficits and speech impairments, was supposed to have communication aids like picture pages and boards as per his care plan. However, during observations, these aids were not found in his room, and both the resident and his sister confirmed they had not seen any communication tools provided. Despite the resident's ability to nod and answer yes or no, the absence of these aids contradicted the care plan's interventions. Similarly, Resident 58, who had moderate cognitive decline and speech impairments following a stroke, was also not provided with the necessary communication aids. His care plan included the use of a steno pad and other augmentative devices to assist with communication. Observations revealed no such aids in his room, and the resident had to use the surveyor's pen and pad to communicate. Interviews with staff indicated that communication tools were not consistently available in the resident's room, despite the resident's ability to write legibly. Interviews with the facility's staff, including the Speech Therapist, LPN, Director of Rehabilitation, and Director of Nursing, revealed a lack of coordination and accountability in ensuring communication aids were available to the residents. The Speech Therapist claimed to have placed communication boards in the rooms, but they were not present during the survey. The Director of Rehabilitation acknowledged difficulties in maintaining these aids in the rooms and expected nursing staff to manage them post-therapy discharge. The facility administrator admitted there was no specific policy regarding communication devices for residents with deficits, leading to inconsistencies in care delivery.