Deficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 40
Capacity: 74
Deficiencies: 7
Nov 29, 2024
Visit Reason
The inspection was a verification visit and complaint investigation triggered by allegations of caregiver misconduct and abuse at Parkside Manor.
Findings
Seven deficient practices were identified, including failure to immediately protect residents from alleged caregiver misconduct, failure to ensure admission agreements were signed, medication labeling issues, improper medication disposition after resident discharge, unsecured oxygen storage, and failure to treat residents with dignity and respect. One complaint was substantiated involving sexual abuse and inappropriate touching by a caregiver.
Complaint Details
One complaint was substantiated involving sexual abuse by Caregiver M who was witnessed inappropriately touching residents and was not immediately removed from resident care. Adult Protective Services substantiated abuse findings.
Deficiencies (7)
| Description |
|---|
| Failure to take immediate steps to protect residents from subsequent episodes of caregiver misconduct and abuse. |
| Admission agreement was not signed and dated before or at the time of admission for Resident 17. |
| Medication labeling deficiency: Resident 18's insulin pen was found without a pharmacy label. |
| Failure to establish effective procedure for handling medications when a resident was discharged; Resident 23's medications were left in the medication cart after discharge. |
| Oxygen cylinder stored upright but not secured in Resident 24's room. |
| Residents 16, 19, 20, 21, and 22 were not treated with courtesy and respect; staff inappropriately touched residents in common areas violating their dignity. |
| Resident 17 did not receive adequate and appropriate care as prescribed; staff used an applicator to apply estradiol cream despite physician order not to use applicator. |
Report Facts
Deficiencies identified: 7
Repeat deficiencies: 3
Revisit fee: 200
Facility licensed capacity: 74
Resident census: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding investigation and handling of abuse allegations. |
| Activity Director N | Activity Director | Received verbal report of sexual assault from Resident 17. |
| Caregiver M | Caregiver | Alleged offender in sexual abuse and inappropriate touching incidents. |
| Caregiver I | Caregiver | Witnessed inappropriate touching by Caregiver M and provided statements. |
| Medication Passer H | Medication Passer | Witnessed inappropriate touching by Caregiver M and provided statements. |
| Wellness Director P | Wellness Director | Interviewed regarding medication and abuse investigation. |
| Associate Administrator O | Associate Administrator | Interviewed regarding abuse investigation and medication issues. |
| Pharmacist W | Pharmacist | Confirmed medication order details and labeling issues for Resident 17. |
| Nurse K | Nurse | Interviewed regarding medication administration for Resident 17. |
| Cook Q | Cook | Reported witnessing inappropriate touching by Caregiver M and resident complaints. |
| Adult Protective Services G | APS Investigator | Conducted investigation and substantiated abuse findings. |
| Regional Vice President R | Regional Vice President of Operations | Filed misconduct incident report regarding abuse allegations. |
Inspection Report
Routine
Census: 41
Capacity: 74
Deficiencies: 5
May 16, 2024
Visit Reason
Surveyors completed a standard survey and 3 complaint investigations. The visit was to assess compliance with medication administration, medication labeling, medication storage, disposal procedures, and food safety.
Findings
Five deficient practices were identified including failure to ensure residents received prescribed medications, medications without proper labeling, improper disposal of expired medications, unlocked medication storage areas, and food safety violations related to temperature control of meals.
Complaint Details
Three complaint investigations were conducted; two complaints were unsubstantiated and one complaint was substantiated related to medication administration.
Deficiencies (5)
| Description |
|---|
| Failure to ensure 3 residents received medications in prescribed dosage and intervals, with multiple missed doses documented. |
| Medications in 2 medication carts lacked pharmacy labels, including insulin pens and inhalers. |
| Expired medications were stored with non-expired medications and medications were retained after resident discharge without proper disposal procedures. |
| Medication storage rooms and refrigerators were found unlocked, allowing potential access to resident medications. |
| Hot food was not held at 140°F or above and cold food not held at 40°F or below until serving, with Styrofoam containers used to keep meals warm but residents reported food often cold. |
Report Facts
Missed medication doses: 18
Missed medication doses: 3
Missed medication doses: 36
Missed medication doses: 9
Missed medication doses: 55
Missed medication doses: 72
Licensed capacity: 74
Current census: 41
Expired insulin pens: 9
Expired Lantus insulin pens: 5
Expired Tresiba pens: 3
Expired medications: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed confirming concerns with medication administration and medication storage security |
| Regional Clinical Director F | Regional Clinical Director | Interviewed confirming concerns with medication administration, medication labeling, audits, and medication storage security |
| Director of Wellness D | Director of Wellness | Responsible for medication audits and reporting missed medications as per Administrator A and RCD F |
| Caregiver C | Interviewed regarding meal delivery process and staffing challenges | |
| Kitchen Staff E | Interviewed regarding meal preparation and delivery responsibilities |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Sep 18, 2023
Visit Reason
Surveyor completed a complaint investigation at Parkside Manor to determine if deficient practices were present.
Findings
No deficient practices were identified during the complaint investigation. The complaint was unsubstantiated.
Complaint Details
Complaint investigation was completed and found unsubstantiated.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Apr 17, 2023
Visit Reason
Surveyor conducted a verification visit and complaint investigation at Parkside Manor.
Findings
Statement of Deficiency 0HU711 was corrected and no new deficiencies were identified. Two complaints were unsubstantiated.
Complaint Details
Two complaints were unsubstantiated.
Report
File
G91712SODS.PDF_18350.pdf
Report
File
UJZS11ENFS.PDF_18350.pdf
Report
File
UJZS12ENFS.PDF_18350.pdf
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