Deficiencies (last 5 years)
Deficiencies (over 5 years)
21.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
430% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Deficiencies: 1
Date: Sep 3, 2025
Visit Reason
The inspection was conducted to assess compliance with medication storage and administration standards at Park View Post Acute.
Findings
The facility failed to ensure medications were stored and maintained according to professional standards when two medication pills were left unattended at a resident's bedside without authorization, creating potential risk for medication errors or harm.
Deficiencies (1)
F 0761: The facility did not ensure drugs and biologicals were labeled and stored in locked compartments as required. Two medication pills were found unattended at Resident 1's bedside without authorization for bedside storage or self-administration.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Confirmed leaving medications unattended at Resident 1's bedside. |
| Director of Nursing | Director of Nursing | Acknowledged the risk of leaving medications unattended at Resident 1's bedside. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 3, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with medication storage and administration regulations at Park View Post Acute.
Findings
The facility failed to ensure medications were stored and maintained according to professional standards when two medication pills were left unattended at the bedside of Resident 1 without authorization, creating potential risk for medication errors or harm to residents.
Deficiencies (1)
Medications were left unattended at Resident 1's bedside without authorization for bedside storage or self-administration.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Confirmed medications were left unattended at Resident 1's bedside |
| Director of Nursing | Director of Nursing | Acknowledged the risk of leaving medications unattended at bedside |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 17, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with medical record-keeping standards and to identify deficiencies related to documentation accuracy.
Findings
The facility failed to maintain accurate medical records for one resident when vital signs were documented after the resident had been transferred out of the facility. This resulted in inaccurate documentation in the resident's medical record.
Deficiencies (1)
F 0842: The facility failed to maintain medical records in a complete and accurate manner for one resident when vital signs were recorded after the resident had been transferred out of the facility. This caused inaccurate documentation in the resident's medical record.
Report Facts
Residents sampled: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the documentation error of vital signs after resident transfer |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 17, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with maintaining accurate and complete medical records, specifically regarding vital signs documentation for residents.
Findings
The facility failed to maintain accurate medical records for one resident when vital signs were documented after the resident had been transferred out of the facility, resulting in inaccurate documentation. The Director of Nursing confirmed the error in documentation.
Deficiencies (1)
Failure to maintain medical records in a complete and accurately documented manner for one resident when vital signs were recorded after the resident had been transferred out of the facility.
Report Facts
Residents sampled: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed the documentation error regarding vital signs after resident transfer |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 2, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care planning and professional standards of care at Park View Post Acute nursing home.
Findings
The facility failed to develop and implement a complete, resident-centered care plan for one resident regarding BIPAP therapy and failed to notify the physician when the BIPAP machine became inoperable and when an ordered medication was not administered. These failures had the potential to cause harm or deterioration in the resident's condition.
Deficiencies (2)
F 0656: The facility failed to develop and implement a complete care plan for Resident 1's BIPAP therapy, decreasing the potential to provide resident-centered care and ensure safety.
F 0658: The facility failed to provide care meeting professional standards by not notifying the physician when Resident 1's BIPAP machine became inoperable and when an ordered medication was not administered.
Report Facts
Residents sampled: 4
Date BIPAP therapy not received: May 11, 2025
Date medication dose missed: May 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD 1 | Medical Doctor | Provided statements on the potential harm from missed BIPAP therapy and medication |
| Director of Nursing | Director of Nursing | Stated expectations for notification regarding broken BIPAP and missed medications |
| Licensed Nurse 1 | Licensed Nurse | Interviewed regarding medication administration and notification procedures |
| Licensed Nurse 2 | Licensed Nurse | Confirmed Resident 1 did not have care plans identifying BIPAP therapy |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed Resident 1 missed BIPAP therapy and medication dose without physician notification |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 2, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to develop and implement a resident-centered care plan and failure to provide care and services in accordance with professional standards for one resident.
Complaint Details
The complaint investigation focused on Resident 1, who did not have a care plan for BIPAP therapy, did not receive ordered BIPAP therapy on 5/11/25 due to a broken machine, and missed a dose of Ozempic on 5/19/25 without physician notification. The failures were confirmed through interviews with medical and nursing staff.
Findings
The facility failed to develop and implement a complete care plan for Resident 1's Bilevel Positive Airway Pressure (BIPAP) therapy and failed to notify the physician when the BIPAP machine became inoperable and when an ordered medication was not administered. These failures had the potential to cause Resident 1's condition to worsen.
Deficiencies (3)
Failed to develop and implement a resident-centered care plan for Resident 1's BIPAP therapy.
Failed to notify the physician when Resident 1's BIPAP machine became inoperable.
Failed to notify the physician when Resident 1 was not administered an ordered medication (Ozempic).
Report Facts
Date of missed BIPAP therapy: May 11, 2025
Date of missed medication dose: May 19, 2025
Medication dose: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD 1 | Medical Doctor | Provided statements regarding the potential harm of missed BIPAP therapy and medication. |
| MD 2 | Medical Doctor | Placed telephone order for Resident 1 to receive BIPAP therapy. |
| Director of Nursing | Director of Nursing (DON) | Stated expectations for notification of broken BIPAP and missed medications. |
| Licensed Nurse 1 | Licensed Nurse | Interviewed regarding medication administration and notification procedures. |
| Licensed Nurse 2 | Licensed Nurse | Confirmed Resident 1 did not have care plans identifying BIPAP therapy. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Confirmed Resident 1 missed BIPAP therapy and medication dose without physician notification. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 29, 2025
Visit Reason
The inspection was conducted due to a complaint regarding medication errors involving Resident 3, specifically incorrect dosing of the medication Uptravi.
Complaint Details
The complaint was substantiated based on interviews with family members and staff, record reviews, and observations confirming medication dosing errors for Resident 3.
Findings
The facility failed to ensure residents were free from significant medication errors when Resident 3 was given the wrong dose of Uptravi multiple times. The medication administration records and interviews revealed that the medication label did not reflect the correct order, leading to potential overdose risks.
Deficiencies (1)
F0760: The facility failed to ensure residents were free from significant medication errors when Resident 3 was given four 200 mcg tablets instead of one 800 mcg tablet as ordered. This error had the potential to cause serious physical harm including organ failure or death.
Report Facts
Medication administrations: 29
Medication tablets per dose: 4
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 29, 2025
Visit Reason
The inspection was conducted due to a complaint regarding medication errors involving Resident 3, specifically that the resident was given the wrong dosage of the medication Uptravi multiple times.
Complaint Details
The complaint was substantiated based on interviews and record reviews showing Resident 3 was given the wrong dose of medication multiple times, leading to concerns from the family and staff about medication stock depletion and incorrect labeling.
Findings
The facility failed to ensure residents were free from significant medication errors when Resident 3 was administered an incorrect dosage of Uptravi, receiving four 200 mcg tablets instead of one 800 mcg tablet per dose as ordered. This error led to medication stock depletion and potential harm to the resident.
Deficiencies (1)
Failure to ensure residents were free from significant medication errors, specifically incorrect dosage administration of Uptravi to Resident 3.
Report Facts
Medication administrations: 29
Medication dosage: 4
Medication dosage: 1
Medication frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff A | Interviewed regarding medication administration and awareness of dosage discrepancy | |
| Director of Nursing | DON | Interviewed about medication stock depletion and order clarification |
| Licensed Staff B | Interviewed about medication administration and family concerns |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 14, 2025
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with professional standards of care and infection prevention protocols at the nursing facility.
Findings
The facility failed to ensure one resident received all scheduled medications and failed to notify the physician of missed medications. Additionally, the facility failed to ensure proper infection control practices were followed by staff entering a resident's room under contact enteric precautions.
Deficiencies (2)
F 0658: The facility failed to ensure one resident received six scheduled medications and did not notify the physician of the missed doses, risking worsening condition or seizure.
F 0880: The facility failed to ensure a speech therapist followed contact enteric precautions by not performing hand hygiene, not wearing gloves and gown before entering, and not washing hands upon leaving the resident's room.
Report Facts
Missed medications: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed missed medications and failure to notify physician |
| pharmacist | Stated missing Levetiracetam dose could cause seizure risk | |
| Infection Preventionist | Infection Preventionist | Confirmed failure to follow contact enteric precautions |
| speech therapist | Speech Therapist | Failed to perform hand hygiene and wear protective gear as required |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 14, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care, medication administration, and infection prevention and control practices at Park View Post Acute nursing facility.
Findings
The facility failed to ensure one resident received all scheduled medications and that the physician was notified of missed medications, posing risks of worsening condition or seizure. Additionally, the facility failed to ensure proper infection control practices were followed by staff entering and leaving a resident's room under contact enteric precautions, risking spread of infection.
Deficiencies (2)
Resident 1 did not receive six of her scheduled medications and the physician was not notified.
Failure to follow contact enteric precautions by a speech therapist, including not performing hand hygiene, not wearing gown and gloves prior to entering the room, and not washing hands upon leaving.
Report Facts
Missed medications: 6
Admission date: Jul 26, 2024
Admission date: Jan 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed missed medications and importance of notifying physician. |
| Infection Preventionist | Infection Preventionist | Confirmed infection control failures and importance of contact enteric precautions. |
| pharmacist | Stated missing Levetiracetam dose could result in seizure risk. | |
| speech therapist | Speech Therapist | Observed failing to follow contact enteric precautions. |
Inspection Report
Deficiencies: 4
Date: May 17, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, notification procedures, care planning, medication administration, fall risk assessment, and overall facility operations at Park View Post Acute.
Findings
The facility failed to notify the Long-term Care Ombudsman of a resident's hospital transfer, did not develop comprehensive care plans for some residents, failed to follow professional standards in medication administration, and inaccurately assessed fall risk for a resident. These deficiencies posed potential risks for resident harm and inadequate care.
Deficiencies (4)
F 0623: The facility failed to notify the Long-term Care Ombudsman of Resident 209's hospital transfer on 2/17/24, as required by regulation.
F 0656: The facility did not develop comprehensive care plans for Resident 78's activities and Resident 209's broken arm, risking inadequate care and resident frustration.
F 0658: Licensed Vocational Nurses left medications without physician orders at bedside and signed for IV medications they did not administer, violating professional standards.
F 0689: The facility failed to accurately assess Resident 209's fall risk by omitting his arm fracture and sling from the assessment, potentially leading to inadequate fall precautions.
Report Facts
Residents sampled: 24
Discharged residents sampled: 4
Medication cups: 6
Potassium dosage: 7.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff G | Completed Notice of Proposed Transfer/Discharge form for Resident 209 | |
| Licensed Staff L | Conducted admission skin assessment for Resident 209 and commented on care plan | |
| Licensed Staff A | Licensed Vocational Nurse | Left medications on Resident 3's bedside table and signed medication administration record |
| Director of Nursing | Director of Nursing | Reviewed care plans, medication administration records, and fall risk assessments |
| Social Services Assistant | Unable to find documentation of Ombudsman notification for Resident 209 | |
| Social Services Director | Social Services Director | Provided facility policy and expectations regarding Ombudsman notifications |
| Licensed Staff N | Reviewed medication administration records and noted LVNs signing for RN medications | |
| Medical Director | Medical Director | Confirmed potassium chloride was a prescribed medication, not a supplement |
| Activities Director | Activities Director | Reviewed activity evaluations and care plans for Resident 78 |
Inspection Report
Deficiencies: 4
Date: May 17, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident notification of transfers and discharges, care planning, medication administration, fall risk assessment, and overall quality of care at Park View Post Acute.
Findings
The facility failed to notify the Long-term Care Ombudsman of a resident's hospital transfer, did not develop comprehensive care plans for some residents, failed to follow professional standards in medication administration, and inaccurately assessed fall risk for a resident. These deficiencies posed potential risks for resident harm and inadequate care.
Deficiencies (4)
Failed to notify the Long-term Care Ombudsman of a resident's hospital transfer.
Did not develop comprehensive care plans for residents, including for a broken arm and activities of interest.
Failed to ensure professional standards in medication administration, including leaving medications without physician orders and LVNs signing for IV medications they did not administer.
Failed to accurately assess fall risk of a resident, omitting fracture diagnosis from the assessment.
Report Facts
Residents sampled: 3
Residents sampled: 24
Discharged residents sampled: 4
Medication cups: 6
Potassium dosage: 7.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff G | Licensed Staff | Completed Notice of Proposed Transfer/Discharge form without resident's name |
| Social Services Assistant | Unable to find documentation of Ombudsman notification for Resident 209's transfer | |
| Social Services Director | Social Services Director | Verified expectation to notify Ombudsman of hospital transfers |
| Licensed Staff L | Licensed Staff | Performed admission skin assessment and noted sling on Resident 209 |
| Director of Nursing | Director of Nursing | Verified care plan deficiencies and fall risk assessment inaccuracies |
| Licensed Staff N | Licensed Staff | Reviewed medication administration records and noted LVNs signing for IV medications |
| Licensed Staff A | Licensed Vocational Nurse | Left medications on Resident 3's bedside table without physician order |
| Medical Director | Medical Director | Confirmed potassium chloride was a prescribed medication, not a supplement |
| Activities Director | Activities Director | Completed activity admission evaluation without interviewing Resident 78 and confirmed lack of supplies |
Inspection Report
Routine
Deficiencies: 13
Date: May 17, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident rights, safety, care planning, infection control, staff training, and environmental conditions.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights and dignity, inadequate notification and access to survey results, uncomfortable noise levels, incomplete care plans, improper medication administration practices, inadequate staff training and competency tracking, unsafe environmental conditions in the kitchen, and infection control lapses related to sanitary storage of urinals.
Deficiencies (13)
Failure to honor residents' rights to dignity, privacy, and timely assistance, including staff using residents' rooms as shortcuts and failure to follow smoking policy.
Failure to update and notify residents of the survey binder containing complaint and incident investigation results.
Failure to ensure a comfortable noise level for residents, resulting in disturbed sleep and resident complaints.
Failure to ensure residents knew how to file grievances and lack of grievance policy communication.
Failure to notify the Long-term Care Ombudsman of a resident's hospital transfer.
Failure to develop comprehensive care plans reflecting residents' needs and preferences, including for fractured arm and activities.
Failure to follow professional standards in medication administration, including leaving medications without orders and LVNs signing for IV medications they did not administer.
Failure to provide activities of interest and supplies to residents who did not participate in social activities.
Failure to accurately assess fall risk for a resident, omitting fracture diagnosis from fall risk assessment.
Failure to ensure nursing staff competencies and mandatory training compliance, including missing annual trainings and incomplete competency documentation.
Failure to provide adequate nursing care and timely response to a resident with respiratory distress and hypoxia, including lack of assessment documentation and failure to notify physician.
Failure to ensure sanitary storage of a resident's portable urinal, increasing risk of infection.
Failure to maintain safe and functional kitchen environment due to cracked and missing floor tiles.
Report Facts
Residents affected: 5
Residents affected: 3
Residents affected: 12
BIMS scores: 15
BIMS scores: 13
BIMS scores: 10
Medication doses: 6
Oxygen liters: 3.5
Pulse rate: 49
Oxygen saturation: 83
Mandatory trainings missing: 3
Years overdue: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff A | Licensed Vocational Nurse | Left medications on Resident 3's bedside table without physician order and signed medication administration record without ensuring medication was taken |
| Licensed Staff B | Licensed Nurse | Failed to assess and document change in condition for Resident 306, lacked updated competencies |
| Licensed Staff C | Licensed Nurse | Interviewed about smoking policy and Safe Smoking Evaluation for Resident 42 |
| Licensed Staff G | Licensed Nurse | Completed Notice of Transfer/Discharge form without resident name for Resident 209 |
| Licensed Staff H | Licensed Nurse | Missing evidence of mandatory trainings |
| Licensed Staff I | Licensed Nurse | Missing evidence of mandatory trainings |
| Licensed Staff J | Licensed Nurse | Missing evidence of mandatory trainings |
| Licensed Staff L | Licensed Nurse | Performed admission skin assessment for Resident 209 but did not document sling or fractured arm |
| Licensed Staff M | Licensed Nurse | Authored initial admission record for Resident 306 |
| Licensed Staff N | Licensed Nurse | Reviewed medication administration records and noted LVNs signing for RN IV flushes |
| Licensed Staff O | Licensed Nurse | Authored care plan for Resident 306 |
| Licensed Staff P | Licensed Nurse | Authored progress note for Resident 306 |
| Activities Director | Coordinated Resident Council meetings, responsible for activity evaluations and care plans | |
| Activities Assistant K | Completed quarterly activity evaluations for residents without interviewing them | |
| Director of Nursing | DON | Verified care plan deficiencies and staff competency issues |
| Medical Records Director | Unable to provide policy on survey binder location and grievance process | |
| Medical Director | Confirmed potassium was a medication, not a supplement | |
| Social Services Director | SSD | Expected staff to notify Ombudsman of hospital transfers |
| Social Services Assistant | Unable to find documentation of Ombudsman notification for Resident 209 | |
| Infection Preventionist | IP | Provided guidance on enhanced barrier precautions |
| Maintenance Supervisor | Acknowledged need to repair kitchen floor tiles | |
| Director of Staff Development | DSD | Provided staff training records and acknowledged tracking system deficiencies |
| Administrator | Unable to provide complete list of mandatory trainings and staff compliance evidence |
Inspection Report
Routine
Deficiencies: 13
Date: May 17, 2024
Visit Reason
Routine inspection survey of Park View Post Acute nursing home to assess compliance with federal regulations regarding resident rights, safety, care planning, infection control, staff training, and facility environment.
Findings
The facility was found deficient in honoring residents' rights, ensuring safe and dignified care, maintaining accurate care plans, providing adequate activities, ensuring staff competency and training, infection control practices, and maintaining a safe environment. Several residents reported delays in staff response, privacy concerns, noise disturbances, and lack of grievance knowledge. Deficiencies were noted in care planning, medication administration, fall risk assessment, and staff training documentation.
Deficiencies (13)
F 0550: Facility failed to honor residents' rights to dignity, privacy, and timely assistance, causing distress and potential harm to multiple residents due to delayed staff response, unsupervised smoking, and staff entering through residents' rooms.
F 0577: Facility failed to update the survey binder with recent complaint and incident investigation results and failed to notify residents of its location, limiting resident access to inspection results.
F 0584: Facility failed to ensure a comfortable noise level for residents, resulting in sleep disturbances and resident complaints about loud staff and students.
F 0585: Facility failed to ensure residents knew how to file grievances, resulting in potential unresolved resident issues.
F 0623: Facility failed to notify the Long-term Care Ombudsman of a resident's hospital transfer, potentially preventing advocacy for the resident.
F 0656: Facility failed to develop comprehensive care plans for residents, including one with a broken arm and another lacking activity plans matching their interests.
F 0658: Facility failed to follow professional standards when a nurse left medications without physician orders at bedside and licensed vocational nurses signed for IV medications they did not administer.
F 0679: Facility failed to provide activities and supplies matching residents' interests, resulting in boredom and lack of engagement for multiple residents.
F 0689: Facility failed to accurately assess fall risk for a resident with a fractured arm, potentially contributing to a fall and inadequate precautions.
F 0726: Facility failed to ensure nursing staff competency and timely response to a resident's change in condition, resulting in inadequate oxygen management and lack of documentation.
F 0880: Facility failed to ensure sanitary storage of a resident's portable urinal, increasing risk of infection transmission.
F 0921: Facility failed to maintain kitchen floor in good repair, with cracks and missing tiles posing risk of dirt accumulation and staff injury.
F 0940: Facility failed to maintain an effective training program and tracking system for mandatory staff trainings, resulting in staff with overdue or missing required trainings.
Report Facts
Residents affected: 5
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Mandatory trainings overdue: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff A | Licensed Vocational Nurse | Left medications at bedside without physician order and signed medication administration record without ensuring medication was taken. |
| Licensed Staff B | Licensed Nurse | Failed to respond appropriately to resident's change in condition and lacked updated competencies. |
| Licensed Staff H | Licensed Nurse | No evidence of completion of mandatory trainings for bowel & bladder, pressure injuries, and urinary tract infections. |
| Licensed Staff I | Licensed Nurse | Had overdue mandatory trainings for Reporting Elder and Dependent Adult Abuse and Sexual Harassment. |
| Licensed Staff J | Licensed Nurse | Had not been provided mandatory annual refresher training on care of LGBTQ resident since 2022. |
| Activities Assistant K | Did not interview residents for activity preferences and copied previous evaluations. | |
| Licensed Staff L | Licensed Nurse | Did not document resident's sling or fractured arm on admission assessment. |
| Licensed Staff M | Licensed Nurse | Authored initial admission record for Resident 306. |
| Licensed Staff N | Licensed Nurse | Reviewed medication administration records and noted LVNs signing for RN IV medication administration. |
| Licensed Staff O | Licensed Nurse | Authored care plan for Resident 306. |
| Licensed Staff P | Licensed Nurse | Authored progress note for Resident 306. |
| Director of Nursing | Director of Nursing | Verified deficiencies in care planning, fall risk assessment, and medication administration. |
| Director of Staff Development | Director of Staff Development | Provided staff training records and acknowledged tracking system deficiencies. |
| Administrator | Administrator | Acknowledged ineffective staff competency tracking system and training compliance issues. |
| Medical Director | Medical Director | Confirmed potassium chloride was a prescribed medication, not a supplement. |
| Licensed Staff C | Licensed Nurse | Interviewed about smoking policy and Safe Smoking Evaluation. |
| Licensed Staff F | Licensed Nurse | Stated staff should not enter/exit through residents' rooms to respect privacy. |
| Licensed Staff G | Licensed Nurse | Completed Notice of Transfer/Discharge form without resident name. |
| Activities Director | Activities Director | Coordinated Resident Council meetings and addressed noise complaints. |
| Social Services Director | Social Services Director | Expected to notify Ombudsman of resident transfers but failed to ensure notification. |
| Social Services Assistant | Social Services Assistant | Could not find documentation of Ombudsman notification for resident transfer. |
| Infection Preventionist | Infection Preventionist | Advised on use of PPE for high contact resident care. |
| Maintenance Supervisor | Maintenance Supervisor | Acknowledged need to repair kitchen floor tiles and replace floor during grease trap project. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 5, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely notification and ensure a safe and orderly discharge of a resident (Resident 41) to a hospital, including failure to notify the resident's responsible party and improper handling of discharge paperwork.
Complaint Details
The complaint involved failure to notify Resident 41's responsible party of his transfer to a hospital and failure to involve the responsible party in discharge paperwork. The resident was deemed incompetent to make medical decisions, but the facility had him sign discharge documents without his representative's consent. The complaint was substantiated based on interviews and record reviews.
Findings
The facility failed to provide timely notice to Resident 41 and his responsible party before transfer to a higher level of care and failed to ensure a safe discharge process. Resident 41, who was deemed incompetent to make medical decisions, was made to sign discharge documents without his responsible party's involvement. The facility staff's actions prevented the responsible party from advocating for Resident 41 during his hospital stay.
Deficiencies (2)
F 0623: The facility failed to provide timely notification to Resident 41 and his representative before transfer to a higher level of care, preventing timely advocacy.
F 0624: The facility failed to ensure a safe and orderly discharge of Resident 41 by having him sign discharge documents despite being deemed incompetent to make medical decisions, without involving his responsible party.
Report Facts
Date of survey completion: Apr 5, 2023
Resident BIMS score: 13
Dates of hospital stay: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Social Service Staff | Involved in obtaining Resident 41's signature on discharge paperwork at hospital |
| Administrator | Provided statements regarding Resident 41's transfer and discharge process | |
| Physician D | Hospital Physician | Deemed Resident 41 lacked capacity to make medical decisions |
| Physician F | Emergency Room Doctor | Documented Resident 41's emergency room visit after assault incident |
| Director of Quality | Hospital 1 | Expressed concern about facility having Resident 41 sign documents without capacity |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 5, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide timely notification and proper discharge procedures for Resident 41, including failure to notify the resident's responsible party prior to transfer and failure to ensure a safe and orderly discharge.
Complaint Details
The complaint investigation focused on Resident 41, who was transferred to a hospital after an altercation at the facility. The facility failed to notify the resident's responsible party timely and had the resident sign discharge paperwork at the hospital despite his incapacity. The responsible party was not informed about the transfer or discharge, preventing advocacy on the resident's behalf.
Findings
The facility failed to provide timely notification to Resident 41 and his responsible party before transfer to a higher level of care and failed to ensure a safe and orderly discharge. Resident 41, deemed incompetent to make medical decisions, was made to sign discharge paperwork at the hospital without his responsible party's involvement, contrary to facility and hospital policies. The facility also failed to notify the responsible party timely and did not follow proper procedures for discharge documentation.
Deficiencies (2)
Failure to provide timely notification to the resident and responsible party before transfer or discharge, including appeal rights.
Failure to ensure a safe and orderly discharge of Resident 41, including having the resident sign discharge documents despite being deemed incompetent to make medical decisions.
Report Facts
Date of survey completion: Apr 5, 2023
Resident BIMS score: 13
Date of hospital transfer: May 18, 2022
Date of discharge paperwork signing: Jun 1, 2022
Duration hospital stay: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Social Service Staff | Obtained Resident 41's signature on discharge paperwork at hospital under instruction of facility attorney |
| Lawyer E | Facility Attorney | Instructed Licensed Nurse C to obtain Resident 41's signature on discharge paperwork |
| Physician D | Hospital Physician | Deemed Resident 41 lacked capacity to make medical decisions |
| Physician F | Emergency Room Doctor | Documented Resident 41's arrival to hospital after altercation |
| Administrator | Facility Administrator interviewed regarding transfer and discharge procedures | |
| Assistant Director of Nursing | ADON | Interviewed about Resident 41's transfer and discharge |
| Director of Quality | Hospital 1 Director of Quality | Expressed concern about Resident 41 signing discharge documents without capacity |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 20, 2023
Visit Reason
Annual inspection survey of Park View Post Acute nursing home conducted to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Mar 20, 2023
Visit Reason
The inspection was conducted as a standard regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 1
Date: Feb 14, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Park View Post Acute, indicating a regulatory inspection was conducted to assess compliance with care standards.
Findings
The facility was cited for deficiency F0684 related to providing appropriate treatment and care according to orders, resident preferences, and goals. The deficiency text is not available, but the level of harm was noted as actual harm affecting a few residents.
Deficiencies (1)
F0684: Provide appropriate treatment and care according to orders, resident preferences, and goals. Level of harm was actual harm affecting a few residents.
Inspection Report
Deficiencies: 1
Date: Feb 14, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements and identify any deficiencies related to resident care and treatment.
Findings
The report identified a deficiency related to providing appropriate treatment and care according to orders, resident preferences, and goals. The deficiency was associated with actual harm affecting a few residents.
Deficiencies (1)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspection Report
Routine
Deficiencies: 13
Date: Nov 5, 2021
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, safety, care planning, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to honor resident activity preferences, inadequate supervision and safety measures for smoking residents, incomplete care planning for residents with wounds, pain, and cognitive impairments, failure to properly manage resident grievances, lapses in infection control practices including PPE use and equipment disinfection, and failure to maintain emergency water storage protocols.
Deficiencies (13)
Failure to honor resident's right to a dignified existence and participation in preferred activities, specifically Resident 68 was kept bedbound despite wanting to attend social activities.
Failure to keep residents' belongings safe, resulting in loss of personal items and upset residents.
Failure to follow grievance policy, including not documenting or investigating resident grievances related to Resident 109's wandering behavior.
Failure to develop and implement complete care plans addressing resident needs including supervision during offsite appointments, smoking care plans, wound care, respiratory monitoring, edema management, and pain management.
Failure to provide a restful environment for residents due to roommate's anxious verbalizations causing distress and sleep disruption.
Failure to provide adequate supervision and safe smoking area for residents who smoke, including lack of fire extinguisher and proper smoking safety supplies.
Failure to provide safe and appropriate respiratory care, including failure to monitor acute respiratory changes for Resident 33 with COPD.
Failure to provide effective pain management for Resident 7, including lack of medication orders for severe pain and failure to develop a person-centered pain care plan.
Failure to ensure medications were labeled, stored, and destroyed according to policy, including expired medications found in medication carts.
Failure to honor resident food preferences consistently, potentially impacting nutritional intake.
Failure of the Quality Assurance and Performance Improvement (QAPI) program to identify and address multiple quality deficiencies including smoking safety, food preferences, emergency water storage, and grievance management.
Failure to implement infection prevention and control program adequately, including improper use of PPE, lack of eye protection, improper cleaning and disinfection of reusable equipment, lack of designated equipment for isolation rooms, and improper emergency water storage.
Failure to maintain and date respiratory equipment and suction supplies for Resident 73, including use of undated and visibly soiled equipment.
Report Facts
Pain scale: 10
BIMS score: 13
BIMS score: 3
BIMS score: 15
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director S | Director of Nursing | Discussed Resident 68's wound care and bedbound status. |
| CNA N | Certified Nursing Assistant | Reported Resident 74 smoking and Resident 68's wound care limitations. |
| LN P | Licensed Nurse | Provided information about Resident 68's activity participation and wound care. |
| Director A | Director of Social Services | Discussed missing resident belongings and grievance process. |
| DON | Director of Nursing | Provided multiple interviews regarding Resident 49's appointment, Resident 68's care, smoking policies, and pain management. |
| LN K | Licensed Nurse | Discussed Resident 7's pain assessment and medication administration. |
| CNA G | Certified Nursing Assistant | Reported Resident 7's pain complaints. |
| LN L | Licensed Nurse | Discussed Resident 33's respiratory status and pain management. |
| IP | Infection Preventionist | Discussed PPE use, infection control policies, and cleaning procedures. |
| Staff CC | Observed providing care to Resident 262 with lapses in PPE use and cleaning. | |
| CNA PP | Certified Nursing Assistant | Observed and interviewed regarding PPE use and care for Resident 262. |
Inspection Report
Complaint Investigation
Deficiencies: 14
Date: Nov 5, 2021
Visit Reason
The inspection was conducted based on complaints and concerns regarding resident rights, safety, care planning, infection control, and quality of life issues at the facility.
Complaint Details
The visit was complaint-related, triggered by multiple complaints including resident rights violations, inadequate supervision, infection control concerns, and failure to address grievances. The complaint investigation found substantiated deficiencies in these areas.
Findings
The facility failed to honor resident rights to self-determination and participation in activities, maintain a safe environment including proper supervision and infection control, develop and implement adequate care plans for residents' needs including pain management and wound care, ensure proper medication storage and labeling, and address grievances appropriately. Deficiencies were noted in supervision of residents, smoking policies, infection prevention practices, and quality assurance processes.
Deficiencies (14)
F 0550: The facility failed to honor Resident 68's right to self-determination by restricting her from participating in social activities despite her verbalizing a desire to attend.
F 0584: The facility failed to keep four residents' belongings safe, resulting in loss of personal items and resident distress.
F 0585: The facility did not follow its grievance policy, failing to document and investigate complaints about Resident 109's wandering behavior, and residents were unaware of how to file grievances.
F 0656: The facility failed to develop and implement complete care plans for multiple residents, including Resident 49's transportation supervision, Resident 68's bedbound status for wound healing, Resident 33's respiratory symptoms and edema, and Resident 74's smoking care plan.
F 0675: The facility failed to honor Resident 38's right to a restful environment, as her roommate Resident 16's anxious verbalizations caused distress and sleep disruption.
F 0679: The facility failed to provide activities consistent with Resident 68's preferences, resulting in her remaining isolated in bed rather than participating in social activities.
F 0689: The facility failed to provide a safe and supervised smoking area, did not provide supervision for cognitively impaired residents, and failed to prevent wandering that caused resident injuries and distress.
F 0695: The facility failed to assess and monitor acute respiratory changes for Resident 33, delaying potential respiratory treatment.
F 0697: The facility failed to provide effective pain management for Resident 7, who reported severe pain but was only medicated for moderate pain and lacked a person-centered pain care plan.
F 0726: The facility failed to recognize medical changes for Resident 33, including leg swelling and wound care, and failed to monitor respiratory symptoms adequately.
F 0761: The facility failed to label, store, and destroy medications according to policy, including expired medications found in medication carts.
F 0800: The facility failed to honor food preferences for residents, including serving disliked foods and confusing dietary orders, potentially affecting nutritional intake.
F 0867: The facility's Quality Assurance and Performance Improvement program failed to identify and address multiple quality deficiencies including smoking supervision, food preferences, emergency water management, and grievance documentation.
F 0880: The facility failed to implement an effective infection prevention and control program, including inadequate PPE use, improper cleaning and disinfection of equipment, lack of designated equipment for isolation rooms, and improper storage and monitoring of emergency water.
Report Facts
Pain scale: 10
BIMS score: 13
BIMS score: 6
BIMS score: 15
BIMS score: 99
BIMS score: 12
Medication expiration date: 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director S | Director | Provided documentation and interviews regarding Resident 68's care and activities. |
| CNA Q | Certified Nursing Assistant | Interviewed regarding Resident 68's ability to get up and participate in activities. |
| LN P | Licensed Nurse | Interviewed regarding Resident 68's wound care and activity participation. |
| DON | Director of Nursing | Interviewed regarding Resident 68's care, Resident 49's appointment, smoking policies, and pain management. |
| Director A | Director of Social Services | Interviewed regarding lost resident belongings and grievance process. |
| LN O | Licensed Nurse | Interviewed regarding smoking incidents and Resident 16's behavior. |
| CNA N | Certified Nursing Assistant | Interviewed regarding Resident 68's wound and smoking incidents. |
| LN M | Licensed Nurse | Interviewed regarding Resident 49's cognitive status and suction equipment. |
| LN K | Licensed Nurse | Interviewed regarding Resident 33's respiratory symptoms and pain management. |
| CNA G | Certified Nursing Assistant | Interviewed regarding Resident 7's pain complaints. |
| IP | Infection Preventionist | Interviewed regarding infection control practices and PPE use. |
Inspection Report
Routine
Deficiencies: 12
Date: Oct 21, 2019
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements for nursing home care and services.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, accommodate resident needs, provide a comfortable environment, timely notification of transfers and discharges, individualized care planning for activities, assistance with activities of daily living, infection control, and proper food handling. The Activities Director lacked required certification and documentation of in-room visits was inadequate.
Deficiencies (12)
Failure to maintain the dignity of residents by not properly covering urinary catheter bags.
Failure to accommodate resident needs such as extension tubing for oxygen and properly fitting wheelchair.
Failure to provide a comfortable environment due to noisy adjustable beds disturbing residents' sleep.
Failure to timely notify the Ombudsman of resident transfers and discharges.
Failure to develop and implement individualized activities care plans for residents, resulting in sensory deprivation and social isolation.
Failure to ensure residents do not lose ability to perform activities of daily living, including failure to offer hand wipes before meals.
Failure to provide care and assistance for hand washing before meals and toileting assistance, resulting in residents feeling neglected and unclean.
Failure to provide appropriate activities including one-to-one in-room visits for bedbound or non-participating residents.
Activity Director lacked required state certification and failed to document in-room visits.
Failure to provide appropriate treatment and care for urinary catheter placement below bladder level.
Failure to follow food safety policy by holding thawed ground turkey rolls in refrigerator for 7 days instead of cooking within 3 days.
Failure to provide annual tuberculosis screening for a resident.
Report Facts
Residents sampled: 22
Turkey rolls thawing days: 7
BIMS scores: 3
BIMS scores: 2
Blood pressure: 152
Blood pressure: 124
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Provided information on proper urinary catheter bag placement | |
| Certified Nursing Assistant B | Provided information on catheter bag covering practices | |
| Director of Nursing | Director of Nursing | Provided information on oxygen tubing and transfer/discharge notification |
| Physical Therapist X | Physical Therapist | Reported on wheelchair fitting issues for Resident 321 |
| Director of Rehabilitation Services | Director of Rehabilitation Services | Reported on wheelchair replacement for Resident 321 |
| Social Services C | Social Services | Provided information on Ombudsman notification process |
| Social Services E | Social Services | Provided information on Ombudsman notification process |
| Activities Director | Activities Director | Discussed activities assessments, documentation, and certification status |
| Certified Nurse Assistant G | Certified Nurse Assistant | Described hand hygiene practices before meals |
| Certified Nurse Assistant C | Certified Nurse Assistant | Provided care to Resident 416 and described calming techniques |
| Certified Nurse Assistant A | Certified Nurse Assistant | Reported Resident 416 did not attend activities during her shifts |
| Human Resource | Human Resource | Provided information on Activities Director hiring and certification |
| Director of Staff Development | Director of Staff Development | Discussed tuberculosis screening and hand hygiene practices |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Oct 21, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity, accommodation of resident needs, comfort, timely notification of transfers and discharges, individualized care planning, activities provision, hand hygiene, assistance with activities of daily living, qualifications of the activities director, proper catheter care, food safety, and infection control.
Deficiencies (12)
F0550: Facility failed to maintain dignity of residents by not properly covering urinary catheter bags, exposing them to residents and visitors.
F0558: Facility failed to accommodate needs of residents by not providing extension tubing for oxygen and providing ill-fitting wheelchair causing pain.
F0584: Facility failed to provide a comfortable environment as electric adjustable beds made loud noises disturbing residents' sleep.
F0623: Facility failed to timely notify the Ombudsman of resident transfers and discharges, delaying advocacy and oversight.
F0656: Facility failed to develop and implement individualized activities care plans meeting residents' needs, resulting in sensory deprivation and social isolation.
F0676: Facility failed to provide hand wipes before meals to residents, increasing risk of infection.
F0677: Facility failed to provide washcloths and toileting assistance before meals to several residents, causing neglect and uncleanliness.
F0679: Facility failed to provide appropriate one-to-one in-room visits and culturally appropriate activities, limiting resident engagement and quality of life.
F0680: Facility's Activities Director lacked required state certification and failed to document in-room visits, impacting quality of activities program.
F0684: Facility failed to ensure urinary catheter bag was positioned below bladder, risking urinary tract infection.
F0812: Facility failed to follow policy for thawing ground turkey rolls, leaving them in refrigerator for 7 days, risking foodborne illness.
F0880: Facility failed to provide annual tuberculosis screening to a resident, risking spread of communicable diseases.
Report Facts
Residents sampled: 22
Turkey rolls thawing days: 7
BIM scores: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Provided statements on proper urinary catheter bag placement | |
| Certified Nursing Assistant B | Provided statements on catheter bag covering | |
| Director of Nursing (DON) | Provided statements on oxygen tubing and Ombudsman notification | |
| Director of Rehabilitation Services (DHS) | Provided statements on wheelchair replacement | |
| Activities Director | Discussed activities assessments, documentation, and certification status | |
| Certified Nurse Assistant G | Provided statements on hand hygiene before meals | |
| Certified Nurse Assistant C | Provided statements on care for Resident 416 | |
| Dietary Services Manager | Provided statements on thawing and storage of turkey rolls | |
| Director of Staff Development (DSD) | Provided statements on tuberculosis screening and hand hygiene |
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