Inspection Reports for
Parkside Homes
200 WILLOW ROAD, HILLSBORO, KS, 67063-1904
Back to Facility ProfileDeficiencies (last 12 years)
Deficiencies (over 12 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
122% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
76% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Mar 17, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error involving a hospice resident.
Complaint Details
The complaint investigation substantiated a medication error where Licensed Nurse C gave five doses of topical Ativan at once to Resident 1 on 01/14/25. The error was discovered on 01/16/25 and staff education was provided.
Findings
The facility failed to prevent a medication error when Licensed Nurse C administered five times the ordered dose of topical Ativan to a hospice resident. The error was discovered two days later and staff education was provided.
Deficiencies (1)
F0760: The facility failed to ensure residents were free from significant medication errors when Licensed Nurse C administered five times the ordered dose of topical Ativan to a hospice resident. The medication error was not discovered until two days later and documentation of the resident's response was lacking.
Report Facts
Residents in census: 38
Medication error dose multiplier: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Licensed Nurse | Administered incorrect dose of Ativan |
| Administrative Nurse B | Administrative Nurse | Reported and provided education regarding medication error |
Inspection Report
Routine
Census: 34
Deficiencies: 18
Date: Oct 8, 2024
Visit Reason
Routine inspection of Parkside Homes nursing facility to assess compliance with regulatory requirements including resident care, safety, infection control, and facility operations.
Findings
The facility had multiple deficiencies including failure to address resident grievances about food temperatures, incomplete advanced directives, failure to notify families of medication changes, inadequate bed hold notifications, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans, unsafe resident supervision, improper medication cart security, unsafe food handling and storage, inadequate infection control practices, and lack of antibiotic stewardship.
Deficiencies (18)
F 0565: The facility failed to address recurring Resident Council concerns about cold food temperatures, risking decreased psychosocial well-being.
F 0578: The facility failed to ensure Resident 16 had a fully completed advanced directive; the DNR was only signed by a physician.
F 0580: The facility failed to notify Resident 35 or their representative of an antipsychotic medication dosage change.
F 0625: The facility failed to provide written bed hold notices to residents 2, 10, and 31 upon hospital transfers, risking loss of bed placement.
F 0637: The facility failed to accurately assess Resident 3 after a significant change in condition, including falls and medication monitoring.
F 0641: The facility failed to accurately complete MDS assessments for Residents 31 and 35 related to catheter use, oxygen, falls, and insulin injections.
F 0655: The facility failed to develop a baseline care plan within 48 hours for Resident 238, lacking fall prevention interventions.
F 0656: The facility failed to develop a comprehensive care plan for Resident 12 addressing enhanced barrier precautions for wounds and infection control.
F 0657: The facility failed to review and revise care plans timely for Residents 24 and 31 after falls, risking uncommunicated care needs.
F 0684: The facility failed to assess and address skin issues for Resident 12, including open wounds and edema, increasing risk for medical complications.
F 0689: The facility failed to provide a safe environment free from accident hazards for Residents 10, 18, 24, 31, and 238, including inadequate supervision and fall prevention.
F 0695: The facility failed to provide safe and appropriate respiratory care for Residents 3, 13, 31, and 4, including improper nebulizer cleaning and oxygen tubing storage.
F 0761: The facility failed to ensure medication carts were locked when unattended, risking resident safety.
F 0804: The facility failed to ensure meals were served at safe and appetizing temperatures; residents complained of cold food.
F 0812: The facility failed to store, prepare, and serve food in a sanitary manner, including unlabeled and undated food items and poor hand hygiene by dietary staff.
F 0880: The facility failed to maintain an effective infection control program including improper sterile technique during PICC dressing change, lack of enhanced barrier precautions, and improper respiratory equipment cleaning.
F 0881: The facility failed to implement an antibiotic stewardship program to monitor appropriate antibiotic use and prevent resistance.
F 0883: The facility failed to provide required pneumococcal and influenza vaccine declination forms for several residents.
Report Facts
Resident census: 34
Residents sampled: 12
Temperature of pureed food: 100
Temperature of hamburger patties: 113
Temperature of chicken: 130
Temperature of gravy: 122
Temperature of pears: 40
Morse Fall Scale score: 95
Morse Fall Scale score: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse C | Infection Preventionist | Reported on antibiotic stewardship and infection control deficiencies |
| Dietary Staff G | Observed with poor hand hygiene and improper food handling | |
| Certified Medication Aide H | Observed leaving medication cart unlocked | |
| Licensed Nurse K | Reported on fall care and supervision expectations | |
| Administrative Nurse B | Reported on antibiotic stewardship and fall care plan updates | |
| Certified Nurse Aide J | Reported on enhanced barrier precautions and resident care |
Inspection Report
Routine
Census: 34
Deficiencies: 17
Date: Oct 8, 2024
Visit Reason
Routine inspection of Parkside Homes to assess compliance with healthcare regulations including resident care, safety, infection control, and medication management.
Findings
The facility had multiple deficiencies including failure to address resident complaints about food temperature, incomplete advanced directives, failure to notify families of medication changes, inadequate bed hold notifications, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans, unsafe resident supervision, improper infection control practices, and food safety violations.
Deficiencies (17)
F 0565: The facility failed to address recurring Resident Council concerns about cold food temperatures, risking decreased psychosocial well-being.
F 0578: The facility failed to ensure Resident 16 had a fully completed advanced directive; the DNR was only signed by a physician.
F 0580: The facility failed to notify Resident 35's responsible party of an antipsychotic medication dosage change.
F 0625: The facility failed to provide written bed hold notices to residents and/or representatives upon hospital transfers, risking loss of bed placement.
F 0637: The facility failed to complete accurate MDS assessments for Resident 35 related to falls and insulin injections, and for Resident 31 related to Foley catheter and oxygen use.
F 0655: The facility failed to develop a baseline care plan for Resident 238 within 48 hours of admission, lacking fall prevention interventions.
F 0656: The facility failed to develop a comprehensive care plan for Resident 12 addressing enhanced barrier precautions for wounds, risking infection spread.
F 0657: The facility failed to review and revise care plans for Residents 24 and 31 timely after falls, risking uncommunicated care needs and further falls.
F 0684: The facility failed to assess and address skin issues including open wounds and edema for Resident 12, risking additional medical problems.
F 0689: The facility failed to provide a safe environment free from accident hazards for Residents 10, 18, 24, 31, and 238, including inadequate supervision and fall prevention.
F 0695: The facility failed to provide safe and appropriate respiratory care for Residents 3, 13, 31, and 4, including improper nebulizer cleaning and oxygen tubing storage.
F 0761: The facility failed to ensure medication carts were locked when unattended, risking resident safety.
F 0804: The facility failed to ensure meals were served at safe and appetizing temperatures; residents complained of cold food.
F 0812: The facility failed to store, prepare, and serve food in a sanitary manner, including unlabeled and unsealed food items and poor hand hygiene by dietary staff.
F 0880: The facility failed to maintain an effective infection control program including sterile technique during PICC dressing change, hand hygiene, and enhanced barrier precautions.
F 0881: The facility failed to implement an antibiotic stewardship program to monitor appropriate antibiotic use and prevent resistance.
F 0883: The facility failed to provide required pneumococcal and influenza vaccine declination forms for several residents.
Report Facts
Resident census: 34
Resident sample size: 12
Temperature of pureed food: 100
Temperature of hamburger patties: 113
Temperature of chicken: 130
Temperature of gravy: 122
Temperature of pears: 40
Morse Fall Scale score: 95
Morse Fall Scale score: 55
Morse Fall Scale score: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse C | Infection Preventionist | Reported on antibiotic stewardship and infection control program deficiencies |
| Dietary Staff G | Observed with poor hand hygiene and improper food handling | |
| Certified Medication Aide H | Observed leaving medication cart unlocked | |
| Licensed Nurse K | Reported on fall care and supervision expectations | |
| Administrative Nurse B | Reported on antibiotic stewardship and fall care plan updates |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Apr 9, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision and a safe environment to prevent the elopement of a cognitively impaired resident.
Complaint Details
The complaint investigation found that Resident 1, with severe cognitive impairment and a risk for elopement, left the facility without staff knowledge on 03/31/24. The facility failed to apply a Wanderguard bracelet or provide adequate supervision. Immediate jeopardy was identified and corrective actions were implemented promptly.
Findings
The facility failed to prevent Resident 1, who had severe cognitive impairment and was at risk for elopement, from leaving the facility without staff knowledge on 03/31/24. The resident eloped for 11 minutes, placing her in immediate jeopardy. Corrective actions were implemented prior to the onsite visit.
Deficiencies (1)
F 0689: The facility failed to provide adequate supervision and a safe environment to prevent the elopement of a cognitively impaired resident with exit seeking behaviors. Resident 1 eloped from the facility on 03/31/24 at 04:49 PM for 11 minutes without staff knowledge, placing her in immediate jeopardy.
Report Facts
Resident census: 38
Duration of elopement: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Observed and interacted with Resident 1 during the elopement incident |
| CNA M | Certified Nurse Aide | Assigned to Resident 1's house and observed behaviors on the day of elopement |
| CNA N | Certified Nurse Aide | Observed Resident 1 in courtyard and assisted in calming her |
| CNA O | Certified Nurse Aide | Worked prior shift and observed behavior changes in Resident 1 |
| LN H | Licensed Nurse | On duty during incident, did not report exit seeking behaviors or apply Wanderguard |
| Administrative Nurse D | Administrative Nurse | Reviewed residents who wander and expected staff to follow policy |
| CNA P | Certified Nurse Aide | Observed Resident 1 before elopement and noted her statements |
| Administrative Staff A | Administrative Staff | Observed area and camera footage related to elopement |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 3
Date: May 12, 2023
Visit Reason
Investigation of a complaint regarding failure to provide a therapeutic diet and 100% supervision during oral intake for Resident 1 (R1) with dysphagia, resulting in choking and aspiration at a facility activity.
Complaint Details
The complaint investigation was triggered by an incident where Resident 1 choked and aspirated at a facility activity on 05/12/2023 due to failure to provide the prescribed therapeutic diet and supervision. The resident became unresponsive, CPR was initiated, and she was transferred to the hospital where she later died. The investigation found failure to follow diet orders and failure to honor the resident's DNR advance directive.
Findings
The facility failed to provide R1 with the prescribed mechanical soft diet and nectar thick liquids with required supervision, leading to R1 choking and aspirating at an activity party. Staff did not prevent R1 from consuming hard shell candies and non-thickened liquids, resulting in respiratory distress, CPR initiation, hospital transfer, and subsequent death. The facility also failed to honor R1's DNR advance directive during the emergency response.
Deficiencies (3)
F0600: The facility failed to protect residents from neglect by not providing Resident 1 with a therapeutic diet and 100% supervision during oral intake, resulting in choking, aspiration, and death.
F0678: The facility failed to honor Resident 1's advance directive and physician order for DNR, initiating CPR despite the DNR status.
F0808: The facility failed to ensure therapeutic diets were provided as prescribed, failing to provide Resident 1 with the correct mechanically altered diet and supervision, leading to aspiration and death.
Report Facts
Resident census: 41
Residents sampled: 6
Residents reviewed for therapeutic diets: 3
Time of choking incident: 1412
Time CPR started: 1444
Time EMS arrived: 1450
Time resident expired: 1555
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Supervised dining room during incident, assisted Resident 1, and was involved in post-incident investigation. |
| CMA R | Certified Medication Aide | Assisted Resident 1 during choking incident, notified nurse, and called 911. |
| CMA S | Certified Medication Aide | Assisted in moving Resident 1 and called for emergency assistance. |
| Activity Staff Z | Activity Staff | Organized activity party, distributed drinks and cupcakes, and placed hard shell candies on tables. |
| Dietary Staff BB | Dietary Staff | Prepared and served food at activity, aware of Resident 1's diet restrictions. |
| Consultant Therapy Staff II | Consultant Therapy Staff | Assisted with CPR and airway management during choking incident. |
| LN G | Licensed Nurse | Assisted with emergency response and suctioning during choking incident. |
| CNA M | Certified Nurse Aide | Assisted in dining room, provided drink to Resident 1, and witnessed incident. |
| Social Service Staff X | Social Service Staff | Discussed advance directives with Resident 1's Durable Power of Attorney. |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 8
Date: Dec 21, 2022
Visit Reason
Annual inspection of Parkside Homes nursing facility to assess compliance with health and safety regulations, including review of resident care, medication management, fall prevention, and environmental safety.
Findings
The facility failed to notify a physician about a resident's pressure injury, failed to update care plans for fall prevention, failed to maintain a safe environment by leaving hazardous materials unsecured and an exit door unlocked, failed to provide appropriate perineal care increasing UTI risk, failed to obtain a stop date for psychotropic medication, and failed to maintain proper medication refrigerator temperature logs.
Deficiencies (8)
F580: The facility failed to immediately notify the physician when Resident 29 had a wound on his left heel, risking delayed treatment and impaired healing.
F657: The facility failed to update care plans for Residents 20 and 25 to include new interventions to prevent falls, placing them at risk of injury.
F686: The facility failed to provide necessary treatment and services to promote healing for Resident 29's left heel pressure injury, risking further injury and delayed healing.
F689: The facility failed to provide a safe environment by leaving paint and glue unsecured and an exit door unlocked without a working alarm, risking resident accidents.
F689: The facility failed to investigate and implement effective fall prevention interventions for Residents 20, 25, and 29, placing them at risk for falls and injuries.
F690: The facility failed to provide appropriate perineal care for Resident 29 by not changing gloves between dirty and clean tasks, increasing risk for urinary tract infections.
F758: The facility failed to obtain a stop date for Resident 17's PRN antianxiety medication, risking unnecessary psychotropic medication use.
F761: The facility failed to maintain proper temperature logs for the medication refrigerator, risking ineffective medication storage.
Report Facts
Resident census: 38
Sample size: 14
Pressure injury measurements: 1.2
Pressure injury measurements: 2.7
Pressure injury measurements: 0.1
Temperature log missing days: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified physician notification failures, care plan issues, and environmental safety concerns |
| Administrative Nurse F | Administrative Nurse | Responsible for updating care plans and fall prevention interventions |
| Licensed Nurse H | Licensed Nurse | Observed and reported on Resident 29's heel wound and treatment |
| Consultant Staff GG | Consultant Staff | Unaware of Resident 29's wound and expected immediate notification |
| Certified Nurse Aide M | CNA | Observed providing perineal care without changing gloves |
| Certified Nurse Aide N | CNA | Observed providing perineal care without changing gloves |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 7
Date: Jul 29, 2021
Visit Reason
The inspection was conducted to investigate complaints regarding residents' rights to mail delivery, notification of Medicare coverage, baseline care plan summaries, care plan revisions following falls, respiratory care practices, and medication administration errors.
Complaint Details
This inspection was complaint-related, investigating multiple issues including mail delivery, Medicare notification, care planning, fall interventions, respiratory care, and medication errors.
Findings
The facility failed to deliver mail on Saturdays, failed to provide Notice of Medicare Provider Non-coverage to some residents, failed to provide baseline care plan summaries, failed to revise care plans following resident falls, failed to implement appropriate fall interventions, failed to properly manage respiratory equipment increasing infection risk, and administered medications to the wrong resident.
Deficiencies (7)
F 0576: The facility failed to ensure residents received mail on Saturdays as mail delivery was stopped despite post office willingness to deliver.
F 0582: The facility failed to provide Notice to Medicare Provider Non-coverage to two residents prior to discharge from skilled services.
F 0655: The facility failed to provide a baseline care plan summary to a resident and representative following admission.
F 0657: The facility failed to revise a resident's care plan following multiple falls, lacking new interventions to prevent further falls.
F 0689: The facility failed to implement new and appropriate interventions for a resident following falls to prevent reoccurring falls.
F 0695: The facility failed to properly store oxygen and suction tubing, failed to change the oxygen humidifier bottle timely, and failed to clean the suction canister, increasing infection risk.
F 0755: The facility failed to accurately administer medications when staff gave one resident medications intended for another due to lack of resident identification policy.
Report Facts
Residents present: 46
Residents reviewed: 21
Residents affected: 10
Falls dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in medication error finding and care plan revision findings |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding mail delivery and fall interventions |
| Certified Medication Aide R | Certified Medication Aide | Administered medications in error to Resident R21 |
| Certified Nurse Aide O | Certified Nurse Aide | Discussed fall prevention practices |
| Licensed Nurse H | Licensed Nurse | Interviewed regarding respiratory care practices |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 5, 2018
Visit Reason
This visit was conducted as a follow-up to verify correction of previously cited deficiencies at the facility.
Findings
The report documents that previously reported deficiencies identified by regulation numbers 26-41-204(i) and 26-41-205(d)(1-2) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-204(i) deficiency was corrected by the revisit date.
Regulation 26-41-205(d)(1-2) deficiency was corrected by the revisit date.
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 3
Date: May 24, 2018
Visit Reason
This is a revisit inspection for correction order 18-60 at an assisted living facility to verify compliance with previous deficiencies related to medication administration and health care services.
Findings
The facility failed to ensure that health care services were provided by qualified staff, specifically a licensed nurse, and failed to ensure a licensed nurse performed assessments for residents self-administering medications. Medication administration records lacked required details and proper oversight by licensed nurses was not maintained.
Deficiencies (3)
KAR 26-41-204(i) Health Care Services Standards of Practice: Operator/CMA B failed to ensure a licensed nurse provided health care services when requesting and receiving medication orders for resident #1031.
KAR 26-41-205(a)(1) Self Administration of Medication: Operator/CMA B failed to ensure a licensed nurse assessed resident #1031's ability to safely self-administer medication before the resident began self-administration.
KAR 26-41-205(d) Facility Administration of Medications: Operator/CMA B failed to ensure medications were administered according to medical orders and professional standards for residents #1031, #1032, #1033, #1034, #1035, and #1036.
Report Facts
Census: 29
Residents sampled: 3
Residents receiving medication management: 6
Medication administration record initials: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator/Certified Medication Aide (CMA) B | Named in multiple findings related to medication administration and failure to ensure licensed nurse involvement |
Inspection Report
Follow-Up
Deficiencies: 4
Date: May 24, 2018
Visit Reason
This revisit inspection was conducted to verify that previously cited deficiencies have been corrected by the facility.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of 05/23/2018.
Deficiencies (4)
26-41-205 (d) (3): Previously cited deficiency corrected as of 05/23/2018.
26-41-105 (f) (1 - 10): Previously cited deficiency corrected as of 05/23/2018.
26-41-104 (d): Previously cited deficiency corrected as of 05/23/2018.
26-41-207 (b) (5-6) (c): Previously cited deficiency corrected as of 05/23/2018.
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 5
Date: Apr 18, 2018
Visit Reason
This is a resurvey of the assisted living facility conducted on 4/16/18, 4/17/18, and 4/18/18 to evaluate compliance with medication administration, resident records, emergency preparedness, infection control, and other regulatory requirements.
Findings
The facility failed to ensure medications were administered according to medical provider's written orders and failed to document medication administration properly. Resident records lacked admission agreements. The facility did not conduct quarterly emergency management plan reviews with residents and staff. The facility failed to comply with tuberculosis screening guidelines for residents and employees.
Deficiencies (5)
KAR 26-41-205(d): Facility failed to ensure all medications and biologicals were administered according to medical care provider's written orders for residents receiving medication management.
KAR 26-41-205(d)(3)(D): Facility failed to ensure medication aides documented administration of each resident's medication immediately before or after administration.
KAR 26-41-105(f)(3): Facility failed to ensure resident records contained admission agreements and any amendments for sampled residents.
KAR 26-41-104(d)(3): Facility failed to ensure quarterly review of emergency management plan with employees and residents.
KAR 26-41-207(c): Facility failed to comply with tuberculosis guidelines by not completing annual TB symptom screens for residents and not ensuring timely TB testing for employees.
Report Facts
Census: 27
Residents sampled: 3
Employee files reviewed: 3
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 18, 2017
Visit Reason
An offsite visit was completed to verify correction of previous deficiencies cited on 2017-09-29.
Findings
The deficiencies from the prior inspection have been corrected and no new non-compliance was found. The facility is in compliance with all regulations surveyed effective 2017-10-27.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 29, 2017
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found a most serious deficiency rated as a 'F' level, 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 reviewed and accepted, resulting in a finding of substantial compliance effective 10/27/17.
Deficiencies (1)
A 'F' level deficiency was cited, indicating widespread noncompliance with potential for more than minimal harm but no actual harm or immediate jeopardy.
Inspection Report
Census: 55
Deficiencies: 8
Date: Sep 29, 2017
Visit Reason
Health Resurvey and Complaint Investigation of Parkside Homes nursing facility.
Findings
The facility had multiple deficiencies including failure to complete comprehensive resident assessments, failure to revise care plans to reflect resident needs and preferences, failure to provide appropriate treatment and monitoring for residents, failure to maintain sanitary food preparation and equipment, and failure to monitor medications with black box warnings.
Deficiencies (8)
F272: Facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for resident #62, missing required documentation in multiple areas including communication, physical functioning, continence, and medications.
F280: Facility failed to revise care plans for 4 residents to reflect toileting preferences, hospice coordination, weight loss interventions, and medication monitoring.
F309: Facility failed to provide appropriate treatment and monitoring for resident #6 with repeated falls, including failure to initiate neurological checks after unwitnessed falls.
F325: Facility failed to ensure timely nutritional interventions for resident #32 receiving diuretic therapy, including lack of follow-up on dietitian recommendations and nutritional supplements.
F329: Facility failed to identify and monitor residents for adverse consequences associated with medications with black box warnings, and failed to monitor blood pressure prior to administration of antihypertensive medication for resident #61.
F371: Facility failed to prepare and serve food under sanitary conditions, including dirty kitchen equipment, unclean food transport carts, and failure to take temperatures of cold foods.
F456: Facility failed to maintain essential equipment in safe and sanitary operating condition, evidenced by a rusted commercial mixer in the dietary department.
F441: Facility failed to implement an effective infection control program, including inadequate tracking and trending of antibiotic use, lack of follow-up on cultures, and failure to document healthcare or community acquired infections.
Report Facts
Resident census: 55
Antibiotic administrations: 72
Cultures: 14
Weight loss: 11.8
Blood pressure readings: 19
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Sep 29, 2017
Visit Reason
This document is a Plan of Correction submitted by Parkside Homes in response to deficiencies cited in a prior survey conducted on 09/29/2017.
Findings
The facility identified multiple deficiencies related to resident assessments, care plan updates, neuro checks after falls, nutrition management, medication regimen monitoring, food sanitation, infection control, and equipment maintenance. Corrective actions and education plans were implemented to address these issues.
Deficiencies (9)
F272-D The facility failed to ensure comprehensive assessments using the RAI system for resident #62 and others. An MDS Coordinator was assigned to oversee and audit the RAI calendar.
F280-E Residents #37 and #29 did not have timely updates to their person-centered care plans. Education was planned for staff on care plan revisions and integration of hospice care plans.
F309-D Neuro checks were not conducted after unwitnessed falls for resident #6 and others. A new nursing practice was implemented to conduct neuro checks after all unwitnessed falls.
F325-D The facility failed to maintain nutrition status for resident #32. A system was established to ensure dietitian orders are authorized by physicians and monitored for signatures.
F329-E Residents (#3, #62, #16, #61) received unnecessary drugs or lacked black box warnings on care plans. Education was provided to pharmacists and medical staff to ensure compliance.
F371-F Food was not prepared and served under sanitary conditions. Dietary education and cleaning schedules were implemented with audits and unannounced compliance checks.
F428-E The residents' drug regimen was not reviewed monthly by a licensed pharmacist as required. Education and audits were planned to ensure black box warnings are noted and irregularities reported.
F441-F The infection prevention and control program was inadequate. A tracking and trending program was to be implemented to prevent and control infections.
F456-F Essential equipment was not maintained in safe operating condition. The commercial mixer was taken out of service and monthly audits were planned to ensure equipment safety.
Report Facts
Deficiencies cited: 9
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 11, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that all previously identified deficiencies have been corrected as of the dates listed, with no uncorrected deficiencies remaining.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 8, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a most serious deficiency at tag F309, rated 'G' with actual harm but not immediate jeopardy. The facility will not be given an opportunity to correct deficiencies before enforcement remedies are imposed.
Deficiencies (1)
Tag F309 was cited with a severity level 'G' indicating actual harm that is not immediate jeopardy. Corrections are required as evidenced by the CMS-2567L.
Report Facts
Denial of payment effective date: Jan 3, 2017
Compliance deadline: Jun 8, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact for questions and informal dispute resolution |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Dec 8, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#108352) regarding the facility's failure to provide necessary care and services to a resident, including inadequate wound care and delayed response to injury.
Complaint Details
The complaint investigation (#108352) found substantiated failures in care related to wound management and delayed medical response after a resident fall.
Findings
The facility failed to document dressing changes for a resident's skin tear until 12 days after admission, applied a medication to which the resident was allergic, did not obtain timely physician orders for wound care, and delayed obtaining an x-ray after the resident fell and complained of wrist pain. The resident sustained a fractured wrist that was not promptly diagnosed or treated.
Deficiencies (1)
F309: The facility failed to provide necessary care and services for a resident's skin tear, including lack of physician orders for dressing changes, failure to document care, and application of an allergenic ointment. The facility also delayed obtaining an x-ray after the resident fell and complained of wrist pain, resulting in delayed diagnosis of a wrist fracture.
Report Facts
Resident census: 44
Sample size: 4
Days delay for dressing change documentation: 12
Hours delay for x-ray order: 34
Pain medication dosage: 325
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 8, 2016
Visit Reason
This document is a Plan of Correction submitted by Parkside Homes in response to deficiencies cited during a complaint investigation.
Complaint Details
This Plan of Correction addresses deficiencies cited in a complaint investigation at Parkside Homes dated 12/08/2016.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations, focusing on nursing documentation, medical history review, physician notification protocols, and pain rating scales.
Deficiencies (1)
F309G: Nursing documentation practices were deficient, including incomplete review of resident medical history and inadequate physician notification for skin tears, injuries, and pain. Nursing staff will be re-educated on these protocols and pain rating scales.
Report Facts
Audit frequency: 2
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valerie McGhee | CEO/Administrator | Submitted the Plan of Correction. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 26, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were marked as corrected and completed as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Feb 26, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection report.
Findings
The plan outlines corrective actions including policy reviews and revisions, staff education, audits of care plans and medication records, and monitoring through Quality Assurance Performance Improvement (QAPI) meetings to ensure compliance and improvement in care delivery.
Deficiencies (8)
F0000 The statement of deficiencies will be taken to the facility's Quality Assurance Performance Improvement Committee on or before February 26, 2016.
F279-D A review of the Care Plan Policy is being completed and revisions will be made to ensure comprehensive care plans are developed timely and appropriately.
F280-D A Skin Protection Policy and related protocols are being developed and implemented to ensure prevention and treatment of skin issues and wounds with appropriate staff education.
F314-D Care Plan Policy revisions and skin protection policies are being reviewed and staff will receive mandatory training to ensure accurate and current care plans.
F323-D Accidents and Incidents and Fall Management Policies are being reviewed and revised to ensure systematic assessment, investigation, and care planning to mitigate harm.
F329-E Medication-related policies including Adverse Drug Reaction and Black Box Warnings are being revised to ensure accurate tracking and monitoring with staff education.
F428-E Policies on Adverse Drug Reaction and Medication Regimen Review are being updated and staff will receive mandatory training to ensure proper monitoring of side effects and warnings.
F441-F An Oxygen Cannula and Tubing Storage Policy is being developed and staff will be educated to ensure proper implementation and compliance.
Report Facts
Date for completion of corrective actions: Feb 26, 2016
Mandatory in-service training date: Feb 19, 2016
Care Plan meeting date for Resident #27: Feb 9, 2016
Inspection Report
Life Safety
Deficiencies: 1
Date: Feb 2, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at an "E" level, indicating no harm with potential for more than minimal harm and no immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited with deficiencies at an "E" severity level under the Life Safety Code survey. These deficiencies indicate no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Date of Life Safety Code survey: Feb 2, 2016
Date of Health survey: Jan 27, 2016
Effective date for denial of payments: Apr 27, 2016
Date for provider agreement termination: Jul 27, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 27, 2016
Visit Reason
The visit was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies 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 February 26, 2016.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 7
Date: Jan 27, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations for multiple complaint numbers.
Complaint Details
The inspection was triggered by complaint investigations #95945, #96157, #95945, and #96157.
Findings
The facility failed to develop comprehensive care plans, failed to monitor and revise care plans for pressure ulcers, failed to implement timely interventions for pressure ulcers, failed to provide adequate supervision to prevent accidents, failed to monitor adverse effects of medications including those with Black Box Warnings, and failed to maintain proper infection control practices including hand hygiene and oxygen equipment handling.
Deficiencies (7)
F279: The facility failed to develop a comprehensive care plan for Resident #55 during a 34-day stay.
F280: The facility failed to review and revise the care plan with appropriate interventions to prevent pressure ulcers for Resident #30.
F314: The facility failed to implement timely interventions to reduce pressure on vulnerable areas for Resident #30 who developed a pressure ulcer.
F323: The facility failed to provide adequate supervision to prevent accidents for Residents #27 and #59 and failed to maintain an environment free from accident hazards.
F329: The facility failed to have a system to monitor adverse effects of medications, including Black Box Warnings, for 5 sampled residents (#43, #4, #9, #59, #31).
F428: The pharmacist consultant failed to notify the director of nursing about the lack of a system to monitor adverse medication effects including Black Box Warnings for 5 sampled residents.
F441: The facility failed to provide a sanitary environment to prevent infection by improper hand hygiene during personal care and wound dressing changes and improper handling and storage of oxygen equipment for multiple residents.
Report Facts
Residents sampled: 14
Residents reviewed for pressure ulcers: 3
Residents reviewed for accidents: 5
Residents reviewed for unnecessary drugs: 5
Residents with medications with Black Box Warnings: 5
Days Resident #55 stayed without care plan: 34
Days Resident #30 received antibiotics: 7
Days Resident #31 received antipsychotic and other meds: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse M | Nurse | Observed performing wound dressing change for Resident #7 with improper glove use. |
| Administrative Nurse A | Administrative Nurse | Verified failures in care plan development, medication side effect monitoring, and infection control practices. |
| Nurse Aide I | Nurse Aide | Observed providing personal hygiene care with improper glove use for Resident #30. |
| Nurse Aide J | Nurse Aide | Observed providing personal hygiene care with improper glove use for Resident #30. |
| Nurse Aide L | Nurse Aide | Observed providing personal hygiene care with improper glove use for Resident #27. |
| Consultant Pharmacist N | Consultant Pharmacist | Verified failure to note or report lack of medication side effect monitoring system. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 30, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all previously reported deficiencies identified by regulation numbers 483.20(d), 483.20(k)(1), 483.25, 483.25(d), and 483.25(h) were corrected by 12/18/2015.
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Dec 18, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Parkside Homes.
Complaint Details
This Plan of Correction is in response to a complaint investigation at Parkside Homes.
Findings
The plan addresses multiple deficiencies related to physician notification protocols, care plan accuracy, fall risk assessment, infection control, and documentation practices. The facility outlines corrective actions including audits, staff education, policy reviews, and ongoing monitoring.
Deficiencies (5)
F0000 The statement of deficiencies will be taken to the facility's Quality Assurance Performance Improvement Committee on or before December 18, 2015.
F279-D Physician Notification Protocol, Notification of a Significant Change in Condition, Nurse Notification of Physician, and Vital Signs Protocol will be reviewed and revised as needed to ensure appropriate notification. Audits and staff education on these policies will be conducted with ongoing monitoring.
F309-D Director of Nurses and MDS Coordinator will audit care plans to ensure accuracy and individualized interventions for residents with dementia. Fall Risk Assessment will be developed and monitored quarterly with continued staff education.
F315-D Physician Notification Protocol and Infection Control Policy will be reviewed and revised. Audits of resident symptoms and treatments will be conducted. Staff will receive education on notification and urinary health measures to avoid UTIs with ongoing monitoring.
F323-G Fall Policy and Fall Investigation Form will be reviewed and revised. Audits of falls and care plans will ensure safety devices are used. Bowel and bladder reviews will be conducted for residents with falls. Weekly fall reviews and staff education on root cause analysis and interventions will continue.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 19, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency in the facility to be a 'G' level. As a result, a denial of payment for new Medicare and Medicaid admissions will be imposed effective February 19, 2016, until substantial compliance is achieved or the provider agreement is terminated.
Report Facts
Denial of Payment Effective Date: Feb 19, 2016
Noncompliance Correction Deadline: May 19, 2016
Civil Money Penalty Threshold: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Date: Nov 19, 2015
Visit Reason
Complaint investigations were conducted based on multiple complaint numbers (#92925, #93061, 93014, 92179) regarding care and safety concerns at Parkside Homes.
Complaint Details
The inspection was triggered by complaint investigations #92925, #93061, 93014, and 92179, which included concerns about care planning, dementia care, urinary tract infections, and fall prevention.
Findings
The facility failed to provide comprehensive care plans for residents with significant changes, failed to provide individualized dementia care interventions, failed to prevent urinary tract infections, and failed to provide adequate supervision and fall prevention interventions, resulting in multiple falls and injuries.
Deficiencies (4)
F279: The facility failed to provide a comprehensive care plan for Resident #4 with significant physical decline, cognition changes, and an open wound, including inadequate monitoring and treatment of a ventriculoperitoneal shunt and wound care.
F309: The facility failed to provide individualized dementia care interventions for Resident #2, who exhibited severe cognitive impairment and behavioral disturbances, resulting in increased confusion and restlessness.
F315: The facility failed to prevent urinary tract infections in Residents #1 and #2, with Resident #2 having multiple UTIs over four months and Resident #1 experiencing untreated pain related to a UTI for four days.
F323: The facility failed to provide a safe environment and adequate supervision to prevent falls for Residents #2, #3, and #6, resulting in multiple falls, injuries, and a fractured hip without proper root cause analysis or effective interventions.
Report Facts
Resident census: 40
UTI positive urinalysis count: 7
Falls: 3
Falls: 5
Falls: 2
Fracture count: 1
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 23, 2015
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously cited deficiencies have been corrected as of the revisit date.
Deficiencies (1)
Regulation 26-43-205 (h) deficiency identified by prefix S2235 was corrected on 03/23/2015.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Mar 20, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify correction of previously cited deficiencies from the prior survey completed on 2/25/2015.
Findings
The report confirms that the deficiencies previously cited under regulations 483.25 and 483.25(l) were corrected as of the revisit date 3/20/2015.
Deficiencies (2)
Regulation 483.25 deficiency identified as F0309 was corrected by 03/20/2015.
Regulation 483.25(l) deficiency identified as F0329 was corrected by 03/20/2015.
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 9, 2015
Visit Reason
The document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey.
Findings
The facility identified issues related to bowel management and physician notification protocols. Corrective actions include staff education, monitoring of bowel movement flag lists, and ensuring adherence to physician orders.
Deficiencies (2)
F309-D: Assessment completed on affected resident with medium hard stool on 2/27/2015. Staff education and monitoring of bowel movement flag lists will be conducted to ensure compliance.
F329-D: Resident physician notified with orders continuing under specified parameters. Staff education on reporting blood sugars and following physician orders will be provided.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 9, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey. It outlines corrective actions to address staffing shortages and ensure compliance with regulations.
Findings
The facility identified staffing shortages and has developed a plan to recruit qualified staff, including posting job openings and encouraging current staff to obtain certifications. Interim measures include using certified staff for medication and personal care and obtaining assistance from a nearby nursing home.
Deficiencies (2)
S2235-F Assisted Living Operator reviewed staffing schedule and posted open positions to hire qualified staff. Interim plan includes using certified staff for care and medications and assistance from a nearby nursing home.
S9999-F Assisted Living Operator reviewed staffing schedule and posted open positions to hire qualified staff. Interim plan includes using certified staff for care and medications and assistance from a nearby nursing home.
Inspection Report
Renewal
Census: 34
Deficiencies: 2
Date: Feb 25, 2015
Visit Reason
The inspection was a licensure resurvey of an assisted living/residential healthcare facility to assess compliance with medication storage and staffing requirements.
Findings
The facility failed to ensure that only licensed nurses or medication aides had access to stored medications and failed to provide continuous qualified nursing staff coverage for the 34 residents during night shifts.
Deficiencies (2)
26-43-205 (h) Medication Storage: The facility failed to ensure that only licensed nurses or medication aides had access to stored medications for the 34 residents. Non-licensed staff and CNAs had keys and delivered medications during some night shifts.
The facility failed to provide continuous qualified nursing staff coverage from 5:00 PM to 5:00 AM for the 34 residents. Some night shifts were staffed by unlicensed, non-certified personnel alone.
Report Facts
Census: 34
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 25, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found isolated 'D' level deficiencies indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Date: Feb 25, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation related to concerns about care and medication management at the facility.
Complaint Details
The visit was triggered by complaints identified as #83156 and #83866, focusing on inadequate care and medication management for specific residents.
Findings
The facility failed to adequately assess Resident #31 for pain and bowel elimination, resulting in no bowel movement interventions or assessments despite complaints of pain and no bowel movements for over 3 days. The facility also failed to follow physician orders for monitoring and reporting outside of parameter blood sugar results for Resident #14.
Deficiencies (2)
F 309: The facility failed to adequately assess Resident #31 for pain and bowel elimination, with no documentation of bowel movements or assessments despite the resident having no bowel movement for 8 consecutive days and complaints of buttock and back pain.
F 329: The facility failed to follow physician orders to notify the physician of Resident #14's blood sugar results outside of prescribed parameters, with no documentation of such notifications despite multiple out-of-range blood sugar readings.
Report Facts
Resident census: 51
Sample size: 11
Residents reviewed for unnecessary medications: 5
Days without bowel movement: 8
Blood sugar readings outside parameters: 7
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 8, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be widespread 'F' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Deficiencies (1)
The facility had widespread 'F' level deficiencies indicating noncompliance with Life Safety Code requirements. These deficiencies posed no immediate jeopardy but had potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Nov 8, 2014
Provider agreement termination date: Feb 8, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gretchen Wagner | Administrator | Facility administrator named in the report header |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
| Joe Ewert | Commissioner | Mentioned in carbon copy (cc) line |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Dec 31, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as indicated in the Plan of Correction.
Findings
The report confirms that deficiencies previously reported under regulations 483.13(c) and 483.25(c) and (h) were corrected by 12/06/2013.
Deficiencies (3)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4): Previously cited deficiencies were corrected by 12/06/2013.
Regulation 483.25(c): Previously cited deficiency was corrected by 12/06/2013.
Regulation 483.25(h): Previously cited deficiency was corrected by 12/06/2013.
Report Facts
Correction completion date: Dec 6, 2013
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Nov 29, 2013
Visit Reason
This document is a Plan of Correction prepared by the facility in response to deficiencies cited during a prior survey. It outlines corrective actions to address compliance issues related to falls reporting, pressure sore prevention, and accident hazard prevention.
Findings
The facility identified deficiencies in reporting untwitnessed falls with injury, prevention and treatment of pressure sores, and maintaining a safe environment with proper use of lift recliner chairs. The Plan of Correction details policy revisions, staff education, resident assessments, and ongoing monitoring to achieve substantial compliance.
Deficiencies (3)
F225-D: The facility lacked substantial compliance with reporting of untwitnessed falls with injury. Corrective actions include policy revisions, staff education, and leadership review of falls to ensure proper reporting.
F314-G: The facility failed to ensure residents without pressure sores did not develop them and that residents with pressure sores received necessary treatment. Actions include policy revision, staff education, resident risk assessments, and care plan updates.
F323-G: The facility did not maintain an environment free of accident hazards related to lift recliner chairs. Corrective measures include policy development, staff education, equipment adjustments, and ongoing resident assessments.
Report Facts
Date of Plan of Correction completion: Dec 3, 2013
Date of Plan of Correction completion: Dec 6, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gretchen Wagner | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 3
Date: Nov 26, 2013
Visit Reason
Health Resurvey and Complaint Investigations #70456, #70463 were conducted to investigate allegations of failure to report falls and provide adequate supervision and care.
Complaint Details
The investigation was triggered by complaints regarding failure to report falls and inadequate supervision leading to resident injuries. The complaints were substantiated as the facility failed to report falls and provide adequate supervision for residents #15 and #39.
Findings
The facility failed to report unwitnessed falls with injury for two cognitively impaired residents to the appropriate state agency. The facility also failed to provide adequate supervision and accident hazard-free environment, resulting in falls and injuries. Additionally, the facility failed to prevent the development of a stage 3 pressure ulcer for one resident with declining mobility.
Deficiencies (3)
F225: The facility failed to report unwitnessed falls with injury of cognitively impaired residents #15 and #39 to the state agency and failed to thoroughly investigate the falls.
F314: The facility failed to provide care and services to prevent the development of a stage 3 pressure ulcer on resident #26's left heel, despite multiple interventions and wound clinic involvement.
F323: The facility failed to provide adequate supervision and a safe environment to prevent accidents for residents #15 and #39, resulting in falls with injuries including fractures and skin tears.
Report Facts
Resident census: 58
Sample size: 14
Residents reviewed for accidents: 3
Stage 3 pressure ulcer size: 5.3
Stage 3 pressure ulcer size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Discussed resident #15's fall and use of recliner controls during risk team meeting | |
| Administrative Staff A | Provided statements regarding resident #15's recliner use, fall reporting, and facility policies | |
| Nurse A | Reported resident #39 had two unwitnessed falls with injury and incomplete investigations | |
| Physician Q | Commented on resident #15's cognition and ability to use recliner controls | |
| Nurse F | Provided wound care to resident #26 and described wound condition | |
| Nurse Aide D | Reported resident #15's behavior with recliner control | |
| Nurse B | Reported staff attempts to secure recliner control for resident #15 | |
| Nurse Aide G | Described resident #26's pain and repositioning assistance | |
| Physical Therapy Staff H | Described resident #26's mobility and activity level | |
| Medical Practitioner J | Commented on resident #26's mobility post-fracture | |
| Maintenance Staff E | Reported no documentation on mattress change for resident #26 |
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 26, 2013
Visit Reason
The inspection was a licensure resurvey to assess compliance for renewal of the facility's license.
Findings
The licensure resurvey resulted in a finding of no deficiency citations for the facility.
Inspection Report
Follow-Up
Deficiencies: 7
Date: Oct 5, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously reported deficiencies identified by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory citations.
Deficiencies (7)
Regulation 483.15(b): Deficiency previously cited was corrected by the revisit date.
Regulation 483.20(g)-(j): Deficiency previously cited was corrected by the revisit date.
Regulation 483.25(h): Deficiency previously cited was corrected by the revisit date.
Regulation 483.25(l): Deficiency previously cited was corrected by the revisit date.
Regulation 483.25(n): Deficiency previously cited was corrected by the revisit date.
Regulation 483.60(c): Deficiency previously cited was corrected by the revisit date.
Regulation 483.60(b), (d), (e): Deficiency previously cited was corrected by the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Sep 14, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction outlines actions to achieve substantial compliance on multiple deficiencies including resident bathing preferences, UTI documentation, medication safety, immunization policies, and medication review processes.
Deficiencies (7)
F242-D: Residents will receive bathing in a way that honors their preferences of when, where, and how they bathe, providing a pleasing environment.
F278-D: Documentation of urinary tract infections will meet MDS 3.0 criteria with audits and staff training to ensure accuracy.
F323-E: The storage room door lock was changed to a lock that stays locked at all times to ensure safety.
F329-E: Audits and care plans will be completed for residents with medications flagged on the black box warning list.
F334-C: Policy was reviewed and revised to include obtaining current immunization information and educating staff and residents accordingly.
F428-E: Consultant pharmacist will review medication records including black box warnings and provide recommendations to physicians and staff.
F431-D: Outdated medications were disposed and monthly audits will be conducted to ensure no outdated medications remain.
Report Facts
Plan of Correction completion dates: Multiple corrective actions have completion dates ranging from 09/15/2012 to 10/05/2012.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gretchen Wagner | Administrator | Submitted the Plan of Correction. |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 7
Date: Sep 6, 2012
Visit Reason
Annual health resurvey of Parkside Homes nursing facility to assess compliance with federal regulations.
Findings
The facility had multiple deficiencies including failure to provide resident choice in bathing, inaccurate resident assessments, unsafe environment hazards, failure to monitor medications with black box warnings, failure to provide influenza and pneumococcal vaccine education, and outdated stock medications.
Deficiencies (7)
F242: Facility failed to provide residents #34, #35, and #75 with choice of tub, shower, or bed bath despite documented preferences.
F278: Facility failed to accurately assess residents #15 and #35, including incorrect coding of urinary tract infections.
F323: Facility failed to maintain a safe environment; unlocked physical therapy storage door with hot Hydroculator posed accident hazard to residents.
F329: Facility failed to identify and monitor residents with black box warning medications on care plans for 8 of 10 sampled residents.
F334: Facility failed to provide education on benefits and risks of influenza and pneumococcal immunizations to residents or their representatives for 5 sampled residents.
F428: Consultant pharmacist failed to notify nursing staff of medication regimen irregularities and facility failed to monitor adverse consequences of black box warning medications for multiple residents.
F431: Facility failed to ensure stock medications were not outdated; expired pneumococcal and influenza vaccines found in medication room.
Report Facts
Resident census: 61
Sampled residents: 27
Residents reviewed for unnecessary drugs: 10
Expired pneumovax vaccine: 1
Expired influenza vaccine: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Verified lack of education on vaccinations and lack of care plans for monitoring black box warning medications | |
| Nurse B | Verified staff had not addressed black box warnings or adverse consequences for medications on care plans or MAR | |
| Nurse C | Verified black box warnings were not on residents' care plans | |
| Administrative Nurse A | Verified residents' care plans did not include black box warning information | |
| Administrative Staff J | Verified facility identified resident choices as a concern including bathing preferences | |
| Nurse Assistant H | Revealed no tub bath available and it was broken | |
| Maintenance Staff I | Verified whirlpool tub was in working order and available | |
| Nurse Assistant G | Revealed no training on whirlpool tub and unsure why it was not in use |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N057004 POC HW8Y11
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as HW8Y11 for the facility with State ID N057004.
Findings
No deficiencies or findings are listed in this Plan of Correction document. It serves as a corrective action response to a previous inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N057004 POC 7ZFW11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N057004 POC 7ZFW12
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N057004 POC 7ZFW13
Visit Reason
This document is a Plan of Correction related to a previous inspection or deficiency report for the facility identified as ASPEN with State ID N057004.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N057004 POC F0YP11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection of Parkside Homes ALF.
Findings
No specific findings are detailed in this document; it serves as a corrective action plan linked to a previous deficiency report.
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