Inspection Reports for Park Place Care Center

The complaint investigation was substantiated with findings of missing controlled medications and drug destruction logs discovered on 09/30/25, and a resident elopement on 09/01/25 where the resident exited the facility unsupervised and was found on a busy road median. The Immediate Jeopardy related to the elopement began on 09/01/25 and ended on 09/03/25 after corrective actions were implemented.

The facility failed to prevent misappropriation of controlled medications stored for destruction, resulting in missing medications and logs. Additionally, the facility failed to adequately supervise a cognitively impaired resident who eloped from the facility and was found in a dangerous location outside. The facility corrected the elopement-related noncompliance before the survey.

The visit was complaint-related due to allegations of verbal and emotional abuse by NA A towards Resident #1 on or around 05/30/25, failure to investigate and report the incident, and failure to timely report and investigate resident-to-resident abuse involving Residents #6 and #7. The Immediate Jeopardy was identified on 07/09/25 and removed on 07/10/25. The facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm.

The facility failed to protect residents from abuse and neglect, including verbal and emotional abuse by a nursing assistant, failure to suspend the alleged perpetrator immediately, failure to conduct thorough investigations, and failure to timely report abuse allegations to the appropriate authorities. An Immediate Jeopardy was identified and later removed, but the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm. Additional findings included failure to timely investigate and report resident-to-resident abuse.

The facility failed to maintain a safe, clean, and homelike environment due to mold found behind wallpaper in three residents' rooms, posing potential health risks. Additionally, the facility did not thoroughly investigate and report allegations of neglect and injury of unknown origin for two residents within the required five working days.

The complaint investigation revealed that Resident #1 was discharged without a 30-day notice after being taken into police custody for charges related to sexual abuse of a minor. The facility did not provide written discharge notification and refused readmission based on facility policy and court findings. The Ombudsman noted Resident #1 had previously won an appeal for a 30-day discharge notice and should be accepted back after arrest and hospital stay.

The facility failed to notify Resident #1 and the resident's representative in writing about the discharge and reasons for discharge when Resident #1 was transferred to police custody on 02/19/2025. The facility did not provide the required 30-day discharge notice and refused to accept Resident #1 back after his court hearing, citing proximity to a school and facility policy on registered sex offenders.

The complaint was substantiated. Resident #1 was found on the floor unattended for about six hours, sustaining an abrasion and bruises. Staff failed to perform required two-hour checks. Both CNA A and LVN B were suspended and later terminated. The facility conducted a thorough investigation and implemented staff training on abuse and neglect.

The facility failed to ensure Resident #1 was free from neglect when staff did not check on him for approximately six hours, resulting in a fall and injury. Staff responsible were suspended and terminated. The facility conducted in-service training on abuse, neglect, and frequent resident checks following the incident.

The facility failed to ensure proper orders, monitoring, dressing changes, flushing, and competency of nursing staff in managing PICC lines for two residents, resulting in an Immediate Jeopardy that was removed on 2025-01-11. The facility implemented in-services, audits, and monitoring to correct deficiencies and prevent infection and harm.

The facility was found deficient in multiple areas including failure to accommodate resident needs (call light accessibility), manage resident funds timely, ensure privacy in mail/package delivery, develop comprehensive care plans addressing daily activities, timely repair of custom wheelchair, maintenance and proper use of respiratory equipment, food safety and sanitation practices, and infection prevention and control measures.

The complaint involved Resident #3 not receiving a timely neurologist appointment as ordered and not receiving respiratory care consistent with the care plan, specifically the use of CPAP for sleep apnea. The complaint was substantiated with findings that the facility failed to schedule the neurologist appointment timely and failed to implement the CPAP care plan.

The facility failed to schedule a neurologist appointment in a timely manner as ordered by Resident #3's cardiologist and failed to implement Resident #3's care plan regarding the use of a CPAP machine for sleep apnea. These failures could place residents at risk of harm, including lack of necessary medical care, decreased quality of sleep, and cardiovascular impairments.

The facility failed to replace a countertop over a set of cabinets in the dining room for about a year during remodeling, resulting in an environment that was not homelike and could diminish residents' quality of life. Multiple staff and a resident confirmed the countertop had been missing for an extended period, and the facility was awaiting installation of a replacement.

The complaint investigation found that Resident #2's responsible party was not notified of the hand fracture until ten days after the incident, and Resident #1 was administered psychotropic medication without a proper documented diagnosis. The responsible party expressed dissatisfaction with the delayed notification. Interviews with staff confirmed expectations for immediate notification of changes in condition.

The facility failed to immediately notify Resident #2's responsible party of a metacarpal fracture, notifying them ten days after the x-ray results were received. Additionally, the facility failed to ensure Resident #1 was prescribed psychotropic medication (Zyprexa) only for a documented mental illness, as the diagnosis for the medication was not appropriate.

The complaint investigation found that the facility did not obtain proper consent for psychotropic medication and did not limit PRN psychotropic medication orders to 14 days as required. The Director of Nursing confirmed these requirements during interviews.

The facility failed to obtain written consent from Resident #1's representative before administering Xanax and failed to limit PRN orders for psychotropic drugs to 14 days or document rationale for extensions. These failures could place residents at risk of not having their preferred representative involved in care decisions and risk of overmedication.

The complaint investigation was triggered by a fall incident involving Resident #1 during a one-person transfer on 11/10/2023, resulting in a forehead laceration and hospitalization. The investigation found staff failed to follow proper transfer protocols and fall prevention measures. Immediate jeopardy was identified and addressed with in-services and monitoring.

The facility failed to ensure adequate supervision and proper transfer techniques for Resident #1, resulting in a fall causing a forehead laceration and an acute compression fracture of the T3 vertebra. Staff failed to maintain hands on the gait belt during transfer and did not implement appropriate fall prevention interventions. Immediate jeopardy was identified due to these failures.

The complaint investigation revealed failures in personal care services including nail care, oral hygiene, and bathing for multiple residents, as well as inadequate monitoring of antibiotic side effects for one resident.

The facility failed to provide adequate nail care for Residents #6, #45, and #67, oral hygiene for Resident #67, and showers according to schedule for Resident #45. This neglect placed residents at risk of embarrassment, dental issues, skin breakdown, and infection. Additionally, the facility failed to monitor Resident #21 for adverse effects of prophylactic antibiotic use.

The complaint investigation was triggered by multiple resident-to-resident altercations in the locked/secured unit involving Residents #1, #2, #3, #4, #5, and #6, resulting in injuries including a fractured hip and head trauma. The facility was found to have insufficient protective measures and monitoring. Immediate jeopardy was identified on 04/25/2023 and removed on 04/27/2023, but the facility remained out of compliance at actual harm level.

The facility failed to protect residents from abuse and neglect, including resident-to-resident physical altercations that caused injuries. The facility also failed to develop and implement comprehensive care plans for residents with skin issues and failed to provide physician-ordered treatment for a resident's rash. Staffing and monitoring were increased but remained insufficient to prevent harm.

The complaint investigation revealed that Resident #1 had not received PT, OT, or ST since admission despite orders dated 02/27/2023. The resident reported decline and unsuccessful attempts to discuss therapy delays with social worker. The Director of Nursing confirmed the care plan was incomplete and not updated timely. The Administrator acknowledged the risk of decline during the 38-day period without therapy services.

The facility failed to provide PT, OT, and ST services to Resident #1 as ordered, and the resident's care plan was incomplete and not updated for 38 days. This failure placed the resident at risk of decline in physical, mental, and psychosocial functioning. The Director of Nursing and Administrator acknowledged the deficiencies and the potential harm to the resident.

The facility was found deficient in multiple areas including failure to accommodate resident needs (call light out of reach), unsafe and unsanitary environment (foul odors, soiled linens, plumbing leaks, standing water), inadequate laundry services leading to missed showers and unclean linens, incomplete care plans for residents, failure to provide scheduled showers and nail care, medication errors exceeding 5%, expired medications found in medication carts, and poor kitchen sanitation with mold, dust, and contamination risks.