Inspection Reports for
Park Lane Nursing Home

All previously reported deficiencies listed with their regulation numbers were corrected as of the revisit date, December 22, 2015.

The survey found the most serious deficiency to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 22, 2015.

The complaint investigation included allegations related to failure to post abuse reporting information, failure to investigate and report a fall with injury, and inadequate care and infection control practices.

The facility was found deficient in multiple areas including failure to post state agency complaint information, failure to thoroughly investigate and report a resident fall with injury, failure to develop and implement comprehensive care plans especially for residents receiving dialysis, failure to provide adequate care and monitoring for residents with fluid restrictions, failure to provide appropriate catheter care and prevent urinary tract infections, failure to provide meals with correct nutritive value for residents on pureed diets, and failure to maintain infection control including improper storage of oxygen equipment and use of inappropriate disinfectants.

The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. An acceptable plan of correction was required to address these deficiencies.

The report documents that deficiencies previously cited under regulations 483.10(b)(4), 483.20(b)(2)(ii), and 483.25(a)(2) were corrected as of 10/10/2014.

The plan addresses deficiencies related to CPR certification for licensed nursing staff, comprehensive assessments for residents with significant changes, and implementation of restorative therapy programs for residents.

The survey found the most serious deficiency in the facility to be a "G" level. As a result, enforcement remedies including denial of payment for new Medicare admissions effective December 23, 2014, were imposed until substantial compliance is achieved or the provider agreement is terminated.

The inspection included a complaint investigation #78831.

The facility failed to ensure all licensed staff had current CPR certification for residents requesting full code status, failed to conduct comprehensive assessments within 14 days after significant changes in physical condition for two residents, and failed to provide restorative services to prevent significant decline in ADL function for two residents after discharge from therapy services.

The survey found the most serious deficiency to be an 'E' level deficiency, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and termination of provider agreement were recommended if substantial compliance is not achieved.

The report confirms that the deficiency identified under regulation 483.25(h) was corrected as of 02/20/2014. No other deficiencies or uncorrected issues were noted.

The plan of correction addresses deficiencies cited in a complaint investigation at Park Lane Nursing Home.

Deficiencies involved failure to update and follow care plans properly, specifically related to alarm checks and fall prevention. The facility developed a care plan protocol, educated nursing staff, and implemented two-hour rounds to ensure alarms are in place and functioning.

The complaint investigation #KS00072196 found substantiated failures related to fall prevention and alarm use for residents #1 and #2.

The facility failed to ensure two of three sampled residents received adequate supervision and use of alarms as care planned to prevent falls. Resident #1 experienced multiple falls resulting in fractures, with staff failing to use alarms as required. Resident #2 also fell due to staff failing to properly use alarms, including failure to plug in a floor alarm.

All previously cited deficiencies were corrected as of the revisit date, with corrections documented for multiple regulatory requirements.

The report confirms that the deficiency identified as S1364 under regulation 26-40-305 (3) was corrected as of 09/13/2013.

The plan details corrective actions for multiple deficiencies including posting of Ombudsman hotline information, updating MDS assessments and care plans, securing oxygen tanks to walkers, monitoring B12 levels, dietary staff training, medication management, laundry procedures, and electrical safety compliance.

The facility was found deficient in multiple areas including failure to inform residents of their rights and complaint procedures, failure to maintain and display survey results, inaccurate resident assessments, incomplete care plans, improper respiratory equipment care, failure to monitor medication effectiveness, unsanitary food handling and storage, expired medications not disposed, and inadequate infection control practices.

All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.

The plan details corrective actions including education, audits, care plan updates, policy revisions, and monitoring related to comprehensive assessments, medication management, infection control, safety devices, and food handling.

The facility failed to complete timely and accurate comprehensive assessments and care plans for residents, failed to provide necessary care including neurological checks after falls and appropriate eating assistance, failed to ensure a safe environment free of accident hazards, failed to maintain drug regimens free from unnecessary medications, failed to serve food under sanitary conditions, and failed to maintain an effective infection control program.

The Plan of Correction outlines corrective actions for multiple deficiencies including posting new posters, updating care plans for residents with falls and dialysis needs, catheter and perineal care, dietary staff training on puree meals, and housekeeping procedures related to oxygen and nebulizer equipment. Monthly monitoring and staff education are planned to ensure compliance.