Inspection Reports for
Park Place Nursing Facility

The facility failed to develop and implement comprehensive care plans addressing oxygen and nebulizer treatments for a resident receiving oxygen therapy, failed to have active physician orders for oxygen administration, failed to revise care plans to reflect updated advance directives, and failed to secure medications and remove expired sterile supplies properly. These deficiencies posed minimal harm or potential for actual harm to a few residents.

The facility was cited for failing to secure medications left unattended on a medication cart and for storing expired sterile resident care items. Additionally, the facility failed to develop a comprehensive care plan including oxygen and nebulizer treatments for one resident receiving oxygen therapy.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to develop comprehensive care plans addressing oxygen and nebulizer treatments, failure to revise care plans to reflect updated advance directives, administering oxygen without a physician's order, and medication storage issues including unsecured medication carts and expired sterile supplies.

The facility was found not in substantial compliance due to failure to ensure the fire alarm was marked red and locked out on the electrical panel, which could potentially affect all residents.

The complaint involved an allegation by Resident R5 that CNA BB molested and raped him. The facility failed to report this allegation to local law enforcement within two hours as required, although it was reported to the State Survey Agency. The allegation was later recanted by the resident. The sample size for employee files reviewed was ten for fingerprint checks and five for abuse reporting.

The facility failed to ensure a fingerprint check was conducted for one CNA and failed to report an allegation of sexual abuse against a resident to local law enforcement within the required timeframe. Interviews and record reviews confirmed these deficiencies.

The facility was found deficient for failing to report an allegation of sexual abuse against a resident to the State Survey Agency and local law enforcement within the required timeframe. Additionally, the facility failed to ensure a fingerprint background check was conducted for one Certified Nursing Assistant. State Health deficiencies were cited during the survey.

Complaints GA00242762 and GA00244005 were substantiated. The facility failed to report an allegation of sexual abuse by CNA BB against Resident R5 to law enforcement within two hours as required, although the State Survey Agency was notified. The allegation involved molestation and rape. The resident later stated the allegation was not true, which influenced the facility's reporting to law enforcement.

The facility failed to ensure a fingerprint background check was conducted for one Certified Nursing Assistant and failed to report an allegation of sexual abuse against a resident to law enforcement within the required timeframe.

The facility was found not in substantial compliance with life safety requirements, including failure to maintain outside emergency lighting, exit sign lighting in the kitchen, and proper clearance below sprinkler heads in multiple storage closets, which could place residents and staff at risk during an emergency evacuation.

The complaint involved allegations that staff were rough during care for resident #2, which was reported late to the state agency (reported 4 days after the allegation). The allegation was substantiated as the facility failed to report timely as required by policy.

The facility failed to timely report suspected abuse for one resident, failed to complete and transmit discharge MDS assessments timely for three residents, and failed to administer medications within one hour of the scheduled time for two residents. Interviews and record reviews confirmed these deficiencies.

The facility failed to provide pharmaceutical services that assured accurate medication administration for two residents (R#13 and R#17), specifically failing to administer medications within one hour of the scheduled time as required by facility policy.

The visit included investigation of multiple complaint intake numbers (GA00218143, GA00218562, GA00220237, GA00220261, GA00221164, GA00224095, GA00228199, GA00229386, GA00230257). The facility failed to timely report abuse allegations for one resident (R#2), reporting four days late after the resident reported staff being 'rough' during care.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to timely report abuse allegations, failure to complete and transmit discharge Minimum Data Set (MDS) assessments timely, and failure to administer medications within one hour of the scheduled time for two residents.

The facility failed to ensure timely notification to a resident's responsible party regarding the resident's death. Specifically, notification to the family of Resident #137 was delayed by approximately three hours after the resident's death.

Three complaint surveys were conducted: GA00217066 was substantiated with a deficiency; GA00215777 and GA00215700 were unsubstantiated.

The facility was found not in compliance with 42 CFR §483.80, with deficiencies including failure to timely notify a resident's responsible party of death and failure to provide ordered specialized rehabilitative services for one resident.

The complaint investigation found that the facility did not notify the responsible party of Resident #137's death until approximately three hours after the death occurred. The facility also failed to provide rehabilitative therapy services to Resident #99 as ordered, due to a mistaken discontinuation related to payment issues. The facility acknowledged these failures and was taking corrective actions.

The facility failed to notify the responsible party of Resident #137's death in a timely manner, notifying them approximately three hours later. Additionally, the facility failed to provide ordered physical, speech, and occupational therapy services to Resident #99 due to payment issues, which were later corrected.

Complaints GA00207523 and GA00207640 were partially substantiated with deficiencies; GA00205978 and GA00210564 were substantiated with deficiencies; GA00207027 and GA00210728 were unsubstantiated.

The facility failed to implement a dedicated COVID-19 unit and observation unit for new admissions, failed to consistently screen staff for COVID-19 symptoms, and admitted COVID-19 positive residents into general population areas without dedicated staff. These failures led to an outbreak with multiple residents and staff testing positive and two resident deaths. The facility implemented corrective actions including establishing dedicated COVID-19 and PUI units, staff screening protocols, staff education, and ongoing monitoring.

The facility was found not in substantial compliance with several regulatory requirements including grievance handling, nurse staffing information posting, food safety and sanitation, use of outside resources, and maintenance of essential equipment.

Complaint investigation related to a resident missing her lower denture and multiple food safety and sanitation concerns in the kitchen.

The facility failed to promptly file a grievance for a resident missing her lower denture and did not maintain proper food safety standards, including uncovered and unlabeled food items, expired food, unsanitary kitchen conditions, improper food holding temperatures, and unsafe food handling practices during pureeing.

The facility was found not in substantial compliance with fire safety requirements, specifically failing to properly maintain the fire alarm and sprinkler systems, including lack of sensitivity testing for smoke detectors, sprinkler piping not protected from freezing, and painted and loaded sprinkler heads.

The facility failed to follow the comprehensive care plan for Resident #40 regarding safe transfer techniques, resulting in two fractured ribs. The ADL communication tool used by CNAs inaccurately documented the resident's transfer needs, leading to improper transfer without assistance or use of a Hoyer lift. Multiple staff interviews and record reviews confirmed the resident was totally dependent and required two-person assistance or a Hoyer lift for transfers.

The investigation revealed that CNA BB, who had never worked with Resident #40 before, transferred the resident without assistance and without using the required Hoyer lift, causing injury. The ADL sheet incorrectly documented the resident as needing one-person assistance, while the resident was actually totally dependent and required two-person assistance or a Hoyer lift. The Director of Nursing confirmed these findings.

The facility staff failed to follow the comprehensive care plan for Resident #40 regarding safe transfer procedures, leading to the resident sustaining two fractured ribs. The care plan and ADL sheet were inconsistent and not properly updated, contributing to the improper transfer by a CNA unfamiliar with the resident's needs.

The facility was found not in substantial compliance with life safety requirements including emergency lighting, hazardous area enclosures, fire alarm system installation and initiation, sprinkler system installation and maintenance, portable fire extinguisher maintenance, smoke barrier construction, utilities maintenance, HVAC makeup air, smoking regulations, and oxygen cylinder storage.