Inspection Reports for
Kindred Transitional Care & Rehab – Park Place

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to ensure a resident with a history of elopements had a wander guard in place and doors were secured, and staff were not aware of or employing appropriate fall interventions for residents at risk of falls.

F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure proper storage of respiratory equipment in resident rooms, proper emptying of full urinals, and proper disposal of trash and recycling in resident rooms.

F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to assist a resident with obtaining clothing that fit and changing clothing regularly, causing the resident to re-wear the same shirts daily and impacting her dignity.

F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely: the facility failed to provide a home-like setting and control unpleasant urine odors on the 400B hallway affecting residents and visitors.

F 0685 Assist a resident in gaining access to vision and hearing services: the facility failed to ensure a resident received timely eye care and did not schedule an eye exam despite repeated requests and documented vision difficulties.

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to timely identify and prevent deterioration of a resident's pressure ulcer, did not consistently document wound status, and failed to manage refusals and pain effectively.

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: the facility failed to assess and provide services to a resident admitted with an indwelling catheter to transition to self-catheterization, delaying restoration of independence and increasing risk of complications.

F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services: the facility failed to provide behavioral health services for a resident showing signs of moderate depression after a stroke and dialysis initiation, with no documented mental health interventions.

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to properly label, date, and discard food items in the kitchen cooler and failed to monitor refrigerator and freezer temperatures.

F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure safe blood draw practices by contracted staff in the dining room, failed to implement proper droplet and contact precautions for residents, and failed to ensure proper hand hygiene and glove use in the kitchen, increasing risk of infection transmission.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to identify a resident's elopement risk and update the care plan with interventions to prevent elopement for one resident until 13 days after the incident.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to identify elopement risks, implement effective interventions, and follow facility policy for two residents who eloped, including failure to monitor placement and function of wander guard bracelets and failure to notify the attending physician and legal representative upon return.

F 0684 Administrator: the facility failed to continuously assess and document a penile ulcer that was progressively worsening in one resident, and wound care was hindered by the resident's behavior.

F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to identify a severe 16% weight loss over two weeks in a dialysis resident due to inconsistent weight monitoring and scale calibration issues.

F 0760 Ensure that residents are free from significant medication errors: the facility failed to ensure a resident received prescribed medications for urinary retention, causing a 15-day omission of treatment.

F 0880 Provide and implement an infection prevention and control program: the facility staff failed to use standard precautions when handling soiled laundry, risking cross contamination.

F 0557 Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions: the facility failed to ensure a resident was clean and changed before a medical appointment, causing embarrassment and humiliation.

F 0610 Respond appropriately to all alleged violations: the facility failed to complete a thorough root cause analysis for a resident's fall with injury, leaving the cause and preventive interventions undetermined.

F 0641 Ensure each resident receives an accurate assessment: the facility failed to complete an accurate MDS assessment regarding bowel and bladder continence for a resident, despite evidence of frequent incontinence.

F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to implement a baseline care plan within 48 hours that addressed the resident's transfer status, weight bearing status, and activities of daily living.

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to complete a comprehensive, person-centered care plan addressing activities of daily living, bowel and bladder status, transfer and weight bearing status, and therapy services.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility neglected to assess and monitor a new admission properly, resulting in missed vital signs, incomplete nursing notes, and improper medication administration, which contributed to the resident's deterioration and death.

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report an incident of neglect of care for a resident who went a weekend without nursing assessments or completed physician admission orders, increasing the risk of deterioration.

F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted: the facility lacked a system to ensure complete and accurate transcription of physician admission orders, resulting in missed medications for a resident with a respiratory infection due to invalid prescription pad orders and delayed order entry.

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility removed staples early without consulting the surgeon and failed to identify signs of infection, leading to septic shock and additional amputation for one resident.

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered: the facility failed to send a reimbursement check within the 30-day required window for one sampled resident.

F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights: the facility failed to provide notification of transfer and ombudsman notification for one sampled resident.

F 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave: the facility failed to provide written notice of the bed-hold policy to one sampled resident or their family.

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident: the facility failed to notify the physician of abnormal vital signs for a resident with multiple comorbidities, leading to inadequate monitoring and care.

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered: the facility failed to send a reimbursement check within the required 30-day window for a discharged resident.

F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge: the facility failed to provide notice of transfer and failed to notify the ombudsman for a resident transferred to the hospital.

F 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer or therapeutic leave: the facility failed to provide written notice of the bed-hold policy to a resident and family after hospital transfer.

F 0636 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months: the facility failed to identify pressure ulcers on admission for a resident, risking inadequate treatment.

F 0637 Assess the resident when there is a significant change in condition: the facility failed to identify a significant decline in a resident's ADL status, hearing, and weight loss, increasing risk of unmet care needs.

F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to develop a baseline care plan for a resident with pressure ulcers four days post admission.

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to develop a care plan addressing a resident's use of cooking equipment and food storage in his room, creating safety risks.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to revise a care plan to include a hearing device used by a resident, limiting communication support.

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to identify, prevent, and treat pressure ulcers for multiple residents, including two Stage IV ulcers requiring hospitalization and wound clinic management.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to address a resident smoking on facility property in violation of policy, and failed to assess and manage fire hazards related to resident use of multiple power strips and an emersion heater.

F 0695 Provide safe and appropriate respiratory care for a resident when needed: the facility failed to replace a torn CPAP mask and failed to date and change oxygen tubing and humidifier bottles for multiple residents as required.

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services: the facility failed to monitor and document post dialysis assessments including vital signs and access site checks for a resident receiving dialysis.

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: the facility failed to provide sufficient nursing staff with annual competencies and skills, including wound care and MDS assessment accuracy, impacting care quality for multiple residents.

F 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis: the facility failed to provide RN coverage for at least 8 consecutive hours daily, seven days a week, contributing to staffing shortages and care deficiencies.

F 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited: the facility failed to ensure GDRs were completed and failed to limit PRN psychotropic medication use to 14 days for multiple residents.

F 0880 Provide and implement an infection prevention and control program: the facility failed to maintain a water management program including flushing and disinfection to minimize waterborne pathogen growth, risking resident exposure.

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention: the facility failed to ensure staff completed required annual training with competencies and failed to maintain training records.