Inspection Reports for
Park View Care Center

The complaint investigation focused on Resident #1 who was hospitalized and subsequently denied re-admission to the facility despite attempts to return on 12/18/25 and 12/19/25. Interviews with Emergency Medical Technicians, hospital staff, the Ombudsman, and facility staff confirmed the facility's refusal to readmit Resident #1, placing him at risk of unsafe discharge. Additional complaints included inadequate care planning for Resident #2 and privacy violations due to broken window blinds.

The facility failed to re-admit Resident #1 after hospitalization, placing him at risk of unsafe discharge. The facility also failed to develop and implement a comprehensive care plan for Resident #2, neglecting to address her wound and non-compliance with care. Additionally, the facility failed to maintain functional window blinds in six resident rooms, compromising resident privacy.

The complaint investigation found that Resident #1's oxygen treatment was not properly coded on the MDS, despite active physician orders and documented refusals of treatment. The facility failed to provide the facility's MDS policy when requested. Interviews with hospice RN, NP, ADON, DON, and Administrator confirmed the resident's oxygen treatment orders and refusal behaviors.

The facility staff failed to ensure that clinical records were accurately documented for Resident #1, particularly failing to code oxygen treatment on the MDS. This failure placed residents at risk of not receiving adequate oxygen care and treatment. Resident #1 had multiple complex diagnoses and an active hospice order for PRN oxygen treatment, but records showed oxygen treatment was not administered as ordered during the lookback period.

The facility failed to maintain a safe, functional, sanitary, and comfortable environment in one of three shower rooms, with issues including torn or missing shower curtains, broken shower heads, and unclean toilets. Additionally, the facility failed to maintain an effective pest control program, resulting in infestations of gnats and flies in multiple areas including nursing stations, dining rooms, and a biohazard closet, posing risks to resident privacy, safety, and quality of life.

The facility failed to establish and maintain an effective infection prevention and control program for one resident on enhanced barrier precautions for ESBL. Specifically, a licensed vocational nurse did not maintain sterile technique during tracheostomy care, using non-sterile supplies and breaking sterile field, which placed residents at risk for infection transmission.

The complaint investigation substantiated that Resident #2 physically assaulted Resident #1 on 07/10/25. Resident #1 sustained a scratch and bruise. The facility took corrective actions including placing Resident #2 on one-on-one supervision and staff in-service training on abuse and neglect.

The facility failed to ensure Resident #1 was free from abuse when Resident #2 physically assaulted him, causing a scratch and bruise. The facility responded by placing Resident #2 on one-on-one supervision and educating staff on abuse prevention. The investigation confirmed the incident and found no additional abuse allegations.

The facility failed to provide medically-related social services to ensure a colonoscopy referral was followed up for Resident #2, risking unmet medical needs and decreased quality of life. Additionally, the facility failed to maintain an infection prevention and control program when a Wound Care Nurse did not wear a gown while providing care to Resident #1 on enhanced barrier precautions, potentially exposing residents to infections.

The complaint investigation was substantiated. Resident #2 struck Resident #1 on 02/18/25 causing redness but no fractures. Police were called, and Resident #2 was taken into custody for a mandatory mental health evaluation and discharged from the facility. Resident #1 had no pain complaints and limited recall of the incident. Staff were re-educated on abuse and neglect policies.

The facility failed to protect Resident #1 from abuse by Resident #2, who struck him causing redness but no fractures. Resident #2 was removed from the facility following police intervention. The facility also failed to assist Resident #3 in obtaining a follow-up dental appointment due to delayed payment of an invoice, potentially causing unnecessary dental pain.

The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding assistance, failure to ensure call lights were within reach, failure to administer oxygen as ordered, failure to follow medication administration protocols for gastrostomy tube residents, medication errors during medication pass, failure to provide safe equipment such as functional bed wheel locks, and failure to maintain an effective pest control program resulting in roach infestations.

The facility was found deficient in maintaining resident dignity during feeding assistance, ensuring call lights were within reach for residents, providing safe and functional equipment such as bed wheel locks, and maintaining an effective pest control program to prevent roach infestations.

The complaint involved allegations that the Administrator verbally abused Resident #1 by cursing at him during a conversation. Resident #1 recorded the conversation and reported feeling unsafe, leading to his discharge. The Administrator admitted to using inappropriate language but denied intent to abuse. The Administrator suspended himself pending investigation.

The facility failed to ensure residents were free from abuse when the Administrator verbally abused Resident #1 by cursing at him during a conversation, which caused the resident to feel unsafe and leave the facility. Additionally, the facility failed to maintain dining room chairs in good condition, which posed a risk to resident comfort and safety.

The facility failed to maintain sanitary conditions in multiple resident rooms and dining rooms, with observations of debris, food particles, soiled items, and presence of roaches. Interviews with residents and staff confirmed ongoing sanitation issues and pest problems despite weekly pest control treatments and housekeeping efforts.

The complaint investigation involved allegations of verbal abuse by a Housekeeping Supervisor towards Resident #2 on 12/10/23, failure of staff (CNA F, Housekeeper G, Social Worker A) to immediately report abuse and exploitation allegations, and failure to timely report these allegations to the State Survey Agency. Resident #1 alleged sexual molestation by CNA B, which was investigated and cleared. Resident #3 alleged misappropriation of money, which was found to be unsubstantiated. The Administrator suspended and banned the Housekeeping Supervisor and reported the abuse to the State Survey Agency after a delay.

The facility failed to protect residents from verbal abuse by a Housekeeping Supervisor, failed to ensure immediate reporting of abuse and neglect incidents by staff, and failed to timely report allegations of abuse and exploitation to the State Survey Agency. The Housekeeping Supervisor was verbally abusive to Resident #2 and was subsequently terminated. Staff failed to report abuse incidents immediately, and the Administrator did not report allegations to the State Survey Agency within required timeframes.

The facility was found deficient in multiple areas including failure to provide private meeting space for resident council, failure to maintain resident privacy, inadequate housekeeping and maintenance, failure to provide appropriate treatment and care per physician orders, medication administration errors, unsafe respiratory care, failure to post daily nurse staffing, unsecured medication storage, food safety violations, infection control lapses, missing call lights for residents, and inadequate staff training.

The facility had multiple deficiencies including failure to provide private meeting space for resident council meetings, failure to maintain resident privacy, inadequate housekeeping and maintenance services, failure to follow up with state mental health authority, lack of organized activities during COVID-19 outbreak, failure to provide appropriate treatment and care according to orders, medication administration errors, unsecured medication storage, inadequate infection prevention and control practices, missing call lights for residents, and environmental issues such as broken window blinds.

The facility failed to develop and implement a complete care plan for Resident #1 that included measurable objectives and timeframes, particularly regarding his complaints about not receiving certain medications and the goals and interventions for seizure and psychotropic medications. This failure could place residents at risk for decreased quality of life and unmet needs.

The complaint investigation revealed that Resident #1, who required two-person assistance for bed mobility and incontinence care, was frequently cared for by only one staff member. This led to two falls on 09/01/23 and 09/02/23, causing a dislocated finger and bruising. The resident refused hospital care but received in-house x-rays confirming injury. Interviews with staff confirmed inadequate staffing during care and lack of awareness of resident's care needs.

The facility failed to ensure adequate supervision and assistance for Resident #1 during incontinence care, leading to the resident falling out of bed twice, resulting in a dislocated finger and bruising. Staff provided care alone despite the resident requiring two-person assistance, increasing risk of injury.

The facility failed to properly secure medications in a locked compartment for one of two nurse medication carts on the South Hall. Observations and interviews revealed that the medication cart was left unlocked and unattended multiple times, placing residents at risk for unauthorized access to medications.

The complaint investigation found that Resident #12 was administered hydroxyzine Pamoate PRN for more than 14 days without physician reevaluation, violating federal guidelines limiting PRN psychotropic drug orders to 14 days unless documented otherwise. The facility did not perform required reevaluations and continued medication beyond 180 days without proper documentation.

The facility failed to ensure that unnecessary antipsychotic medications were not administered without adequate rationale and failed to reevaluate the use of a PRN anti-anxiety medication for Resident #12 beyond the 14-day limit. Resident #12 received hydroxyzine Pamoate for 199 days without physician reevaluation, contrary to federal and facility guidelines.

The facility failed to establish and maintain an effective infection prevention and control program, specifically noting that a CNA did not perform hand hygiene after incontinence care and failed to clean the bedside table, potentially placing residents at risk of infection.

The complaint involved Resident #18 who sustained a knee injury during wheelchair transport that was not reported to the abuse coordinator. Interviews revealed staff failed to report the incident, and the abuse coordinator (Administrator) was not notified. Additionally, multiple medication errors were identified involving administration of a discontinued narcotic to Resident #18.

The facility failed to report an alleged injury to the abuse coordinator after Resident #18 sustained a potential knee injury during wheelchair transport. Additionally, the facility failed to ensure residents were free from significant medication errors, as multiple staff administered a discontinued narcotic to Resident #18, violating physician orders and facility policies.