Inspection Report Summary
The most recent inspection on June 30, 2025, confirmed compliance with federal requirements and found no deficiencies. Prior inspections, however, identified various deficiencies related to staffing levels, failure to report and investigate allegations of verbal abuse, and documentation issues involving resident care plans and monitoring. Complaint investigations substantiated violations concerning staff-to-resident interactions and care plan development, but enforcement actions such as fines or license suspensions were not listed in the available reports. Earlier inspections also noted challenges with infection control during the COVID-19 pandemic and inconsistent use of personal protective equipment. The facility appears to have addressed many prior deficiencies, showing improvement in recent inspections.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
95% occupied
Based on a December 2424 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 138
Capacity: 145
Deficiencies: 0
Dec 19, 2424
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Investigation #41649 and #42557.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as referenced in an attached violation letter dated 2025-01-15.
Complaint Details
Complaint Investigation #41649 and #42557 triggered the inspection. Violations were substantiated as noted.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Johnson | Administrator | Personnel contacted during the inspection. |
| Terri Anderson-Murray | RN | Report submitted by. |
Inspection Report
Monitoring
Census: 136
Capacity: 145
Deficiencies: 14
Jun 30, 2025
Visit Reason
A desk audit was completed to review the implementation of the Plan of Correction for the EID of 4/11/25.
Findings
Multiple deficiencies (F565, F568, F584, F657, F660, F684, F688, F698, F725, F804, F812, F880, F921, and F926) were identified as corrected as of 5/23/25. Compliance was confirmed federally on 6/30/25.
Deficiencies (14)
| Description |
|---|
| F565 deficiency |
| F568 deficiency |
| F584 deficiency |
| F657 deficiency |
| F660 deficiency |
| F684 deficiency |
| F688 deficiency |
| F698 deficiency |
| F725 deficiency |
| F804 deficiency |
| F812 deficiency |
| F880 deficiency |
| F921 deficiency |
| F926 deficiency |
Report Facts
Licensed Bed Capacity: 145
Census: 136
Date of desk audit: Jun 30, 2025
Deficiencies corrected: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Nugent | ADNS | Personnel contacted during inspection and notified of federal compliance |
Inspection Report
Plan of Correction
Capacity: 145
Deficiencies: 0
Feb 13, 2025
Visit Reason
A desk audit was conducted to review supporting documentation for the submitted plan of correction at Parkville Care Center.
Findings
The corrections were approved as completed on 2025-01-21 with no new compliance issues identified during the desk audit.
Report Facts
Licensed Beds: 145
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Johnson | Administrator | Personnel contacted during the inspection |
| Linda Gagnon | HPS | Surveyor conducting the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 19, 2024
Visit Reason
An unannounced visit was conducted at Parkville Care Center on December 19, 2024, by the Department of Public Health to investigate multiple allegations, including staff to resident verbal abuse.
Findings
The investigation found that the facility failed to report an allegation of verbal abuse by staff towards a resident to the State Agency as required. The Director of Nursing investigated but could not substantiate the allegation and did not report the incident. The facility's abuse policy requires all allegations to be promptly reported and investigated.
Complaint Details
The complaint involved an allegation of verbal abuse by a nurse aide towards Resident #1 on 10/24/24. The Director of Nursing investigated but could not substantiate the allegation and did not report it to the State Agency, which was a violation of policy.
Deficiencies (1)
| Description |
|---|
| Failure to report an allegation of staff to resident verbal abuse to the State Agency as required by policy. |
Report Facts
Date of incident: Oct 24, 2024
Date of investigation interview: Dec 19, 2024
Date of Minimum Data Set assessment: Sep 19, 2024
Date of Resident Care Plan: Oct 31, 2024
Date of nurse's note: Oct 24, 2024
Date of correspondence: Nov 14, 2024
Date of abuse policy: Mar 20, 2023
Plan of correction submission deadline: Jan 25, 2025
Plan of correction effective date: Jan 21, 2025
Audit period: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Johnson | Administrator | Recipient of the notice letter |
| Director of Nursing | Director of Nursing | Interviewed on 12/19/24 regarding the verbal abuse allegation; investigated but did not substantiate the claim |
Inspection Report
Plan of Correction
Census: 140
Deficiencies: 1
Sep 28, 2023
Visit Reason
Unannounced visits were made to Parkville Care Center by the Department of Public Health representatives to conduct multiple investigations related to regulatory compliance.
Findings
The facility failed to meet staffing levels as required by the Connecticut Public Health Code on multiple dates in September 2023, with documented understaffing of nurse aide hours. The Administrator acknowledged responsibility but could not explain the staffing shortfalls. A plan of correction was submitted to address these issues.
Complaint Details
Complaint CT #s 35609, 35779 were investigated; substantiation status is not stated.
Deficiencies (1)
| Description |
|---|
| Failure to meet staffing levels in accordance with the Connecticut Public Health Code, with understaffing of nurse aide hours by 40 to 44.4 hours on sampled days. |
Report Facts
Census: 139
Census: 140
Required nurse aide staffing hours: 222.4
Required nurse aide staffing hours: 224
Actual nurse aide staffing hours: 178
Actual nurse aide staffing hours: 184
Understaffing hours: 44.4
Understaffing hours: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Golas-Markure | Supervising Nurse Consultant | Signed letter from Facility Licensing and Investigations Section |
| Administrator | Interviewed on 2023-09-21 regarding staffing compliance |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 145
Deficiencies: 0
Sep 21, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #35609 & #35779.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection. A violation letter dated 10.18.2023 is attached for details.
Complaint Details
Complaint Investigation #35609 & #35779 were the basis for the visit. Violations were substantiated as indicated by the attached violation letter.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Miranda Wilmot | DNS | Personnel contacted during the inspection. |
| Laurie Cianci | Administrator | Personnel contacted during the inspection. |
| Nicholas Tomczyk | Nurse Consultant | Report submitted by. |
Inspection Report
Renewal
Census: 139
Capacity: 145
Deficiencies: 0
Jun 27, 2023
Visit Reason
The inspection visit was conducted as a renewal licensing inspection and included review of complaint investigations identified by numbers CT33052, CT28077, and CT28399.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were identified, with attached violation letters referenced. Additional information was obtained after the onsite inspection dates.
Complaint Details
Complaint investigations referenced by numbers CT33052, CT28077, and CT28399 were reviewed during the inspection. No substantiation status is explicitly stated.
Report Facts
Licensed Bed Capacity: 145
Census: 139
Inspection Dates: Onsite inspection dates from 2023-06-25 to 2023-06-27
Additional Information Date: Additional information obtained on 2023-07-13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Conci | Administrator | Personnel contacted during inspection |
| Miranda Wilmot | DUS | Personnel contacted during inspection |
Inspection Report
Deficiencies: 2
Mar 29, 2022
Visit Reason
Office/telephone conference held to discuss disputed violations from a prior recertification survey dated 06/24/21, specifically violations #3, 4, 5, 9, 10, and 12, with the facility withdrawing requests to dispute violations #14 and 15.
Findings
Violation #3 was moved into violation #1, and violations #4, 5, 9, 10, and 12 were deleted. A revised violation letter was issued on 04/28/22.
Deficiencies (2)
| Description |
|---|
| Violation #3 moved into violation #1 |
| Violations #4, 5, 9, 10, and 12 deleted |
Report Facts
Violation numbers discussed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Norma Schubert | Supervising Nurse Consultant | Signed the summary and action section of the report |
| Karen Gworek | SUS | Listed as present at the conference |
| Robert Burke | VP Psychosocial SUS | Listed as present at the conference |
| Angela Perry | Admin. | Listed as present at the conference |
| Miranda Wilmont | DNS | Listed as present at the conference |
| Alison Breault | CCD | Listed as present at the conference |
Inspection Report
Follow-Up
Census: 120
Capacity: 150
Deficiencies: 1
Mar 18, 2022
Visit Reason
A desk audit review was conducted on 3/18/2022 to review the plan of correction for a violation letter dated 1/19/2022.
Findings
The review identified that violation 1a had been corrected. The desk audit confirmed compliance with the corrective actions submitted by the facility.
Deficiencies (1)
| Description |
|---|
| Violation 1a identified in the previous inspection was corrected. |
Report Facts
Licensed Bed Capacity: 150
Census: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Perry | Administrator | Personnel contacted during the inspection and named in the report. |
| Janet Rosato | RN NC | Report submitted by Janet Rosato RN NC. |
Inspection Report
Follow-Up
Census: 120
Capacity: 150
Deficiencies: 0
Mar 18, 2022
Visit Reason
A desk audit review was conducted to review the plan of correction for the violation letter dated 1/19/2022.
Findings
The review identified that violation 1a has been corrected as of the date of the desk audit.
Report Facts
Licensed Bed Capacity: 150
Census: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janet Rosato | RN NC | Representative of FLIS who conducted the desk audit and submitted the report |
| Angela Perry | Administrator | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 150
Deficiencies: 1
Jan 11, 2022
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint Investigation #31338 to assess violations of Connecticut State regulations at Parkville Care Center.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified during the inspection. Specifically, the facility failed to ensure neurological checks were monitored and recorded for 48 hours after a resident sustained an unwitnessed fall and bruising, indicating deficient clinical record review and documentation.
Complaint Details
Complaint Investigation #31338 was substantiated with violations identified. The facility was required to submit a plan of correction by January 29, 2022.
Deficiencies (1)
| Description |
|---|
| Failure to ensure neurological checks were monitored and recorded for 48 hours after Resident #1 sustained an unwitnessed fall and bruising to the left side of the eye. |
Report Facts
Licensed Bed Capacity: 150
Census: 113
Plan of Correction Completion Date: Jan 29, 2022
Bruise Measurement: 2
Bruise Measurement: 1
Aspirin Dosage: 81
Incident Form Date: Dec 1, 2021
Neurological Check Duration: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aneta Predka | Survey Team Leader | Named as Survey Team Leader on inspection report. |
| Karen Gworek | Supervising Nurse Consultant | Signed the important notice letter and involved in complaint investigation. |
| Sheniqua Jones | ADON | Personnel contacted during inspection. |
| Angela Perry | Administrator | Personnel contacted and recipient of the important notice letter. |
Inspection Report
Renewal
Census: 115
Capacity: 150
Deficiencies: 0
Jun 18, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection for Parkville Care Center.
Findings
No violations or citations were identified during this renewal inspection. Certification file and fund verifications were completed.
Report Facts
Licensed Bed Capacity: 150
Census: 115
Inspection Dates: 5
Inspection Report
Renewal
Census: 115
Capacity: 150
Deficiencies: 0
Jun 18, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of Parkville Care Center to verify compliance with state regulations and licensing requirements.
Findings
The inspection found no violations of the General Statutes of Connecticut or regulations at the time of the inspection. A desk audit review conducted later confirmed that previously identified violations had been corrected.
Report Facts
Licensed Bed Capacity: 150
Census: 115
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 29, 2021
Visit Reason
An unannounced visit was conducted to investigate allegations of mistreatment at Parkville Care Center.
Findings
The facility failed to develop a comprehensive care plan addressing sexually inappropriate behavior for Resident #4 and failed to consistently document fifteen-minute checks for Resident #1 while on observational status. The facility disputed the findings but agreed to corrective actions including staff education and audits.
Complaint Details
The investigation was triggered by allegations of mistreatment involving residents exhibiting inappropriate sexual behavior. The facility disputed the findings and requested an Informal Dispute Resolution.
Deficiencies (2)
| Description |
|---|
| Failure to develop a comprehensive care plan addressing Resident #4's sexually inappropriate behavior towards other residents. |
| Failure to consistently document fifteen-minute checks for Resident #1 while on observational status. |
Report Facts
Plan of correction submission deadline: Feb 27, 2021
In-service education completion date: Feb 26, 2021
Audit duration: 30
Observation documentation shifts missed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Ruot | Supervising Nurse Consultant | Signed the notice letter regarding the investigation. |
| George Kingston | Administrator | Facility administrator addressed in the notice. |
| Director of Nursing | Interviewed regarding deficiencies and responsible for overseeing plan of correction. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 29, 2021
Visit Reason
An unannounced visit was made to Parkville Care Center on 1/29/21 by a representative of the Facility Licensing & Investigations Section for the purpose of conducting a complaint investigation.
Findings
The facility failed to develop a comprehensive care plan for residents with allegations of mistreatment, including failure to document appropriate interventions for sexually inappropriate behavior and failure to consistently document 15-minute checks for a resident on one-to-one observation. The facility is in disagreement with the findings and has requested an Informal Dispute Resolution.
Complaint Details
The complaint investigation was triggered by allegations of mistreatment involving residents. The facility failed to develop a comprehensive care plan for one resident with sexually inappropriate behavior and failed to consistently document 15-minute checks for another resident on one-to-one observation. Resident #4 continues to be free from any allegations of mistreatment. Resident #1 continues to be free from any allegations of mistreatment.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility must develop and implement a comprehensive person-centered care plan for each resident, including measurable objectives and timeframes to meet medical, nursing, and psychosocial needs. | D |
| The facility must maintain resident medical records that are complete, accurately documented, readily accessible, and systematically organized, safeguarding resident-identifiable information. | D |
Report Facts
Deficiencies cited: 2
Completion date for plan of correction: 3/12/2021
In-service education completion date: 2/26/2021
Audit period: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding resident behavior and care plan deficiencies; responsible for overseeing plan of correction |
Inspection Report
Abbreviated Survey
Census: 102
Capacity: 150
Deficiencies: 1
Jul 25, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the transmission of COVID-19.
Findings
The facility failed to ensure that face masks were worn by staff and residents as recommended by the CDC during the COVID-19 pandemic. Observations included staff and residents not wearing masks properly or at all in various situations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure face masks were worn by staff and residents as recommended by CDC during the COVID-19 pandemic. | SS=D |
Report Facts
Capacity: 150
Census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NA#1 | Nursing Assistant | Observed not wearing face mask properly while pushing a soiled linen cart |
| NA#2 | Nursing Assistant | Observed not wearing face mask in resident's room |
| RN#1 | Registered Nurse | Interviewed regarding staff mask wearing practices |
| Director of Nursing | Director of Nursing | Interviewed regarding mask wearing policies and staff education |
| Receptionist | Observed and interviewed about not wearing face mask while talking with staff and resident |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 25, 2020
Visit Reason
An unannounced visit was made to Parkville Care Center to conduct a COVID-19 Focused Infection Control Survey with additional information received through July 25, 2020.
Findings
The facility was found to have violations related to failure to ensure staff and residents wore face masks as recommended by the CDC during the COVID-19 pandemic. Specific observations included staff and residents not wearing masks properly or at all during the visit.
Deficiencies (1)
| Description |
|---|
| Failure to ensure face masks were worn by staff and residents as recommended by the CDC during the COVID-19 pandemic. |
Report Facts
Observation time: 1115
Observation time: 1130
Observation time: 1145
Observation time: 1230
Audit period: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa A. DiLorenzo | Supervising Nurse Consultant | Signed letter regarding violations and plan of correction |
| Cori Knutsen | Administrator | Recipient of the notice letter |
Inspection Report
Abbreviated Survey
Census: 116
Capacity: 150
Deficiencies: 1
Jun 2, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the transmission of COVID-19.
Findings
The facility failed to ensure that medically approved personal protective equipment (PPE) was worn while in resident care areas, specifically a nursing assistant was observed wearing a cloth mask instead of a surgical mask. The facility disagreed with the findings and requested an Informal Dispute Resolution. The facility plans to provide inservice education on approved PPE and conduct weekly audits to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Failure to adhere to infection control practice to ensure that medically approved personal protective equipment (PPE) was worn while in a resident care area. |
Report Facts
Total Capacity: 150
Census: 116
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Assistant #1 | Observed wearing a cloth mask instead of a surgical mask while exiting a resident room | |
| Director of Nursing | Interviewed regarding PPE requirements and facility policies |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 2, 2020
Visit Reason
An unannounced visit was made to Parkville Care Center to conduct a COVID-19 Focused Survey with additional information received through June 2, 2020.
Findings
The facility failed to adhere to infection control practices by allowing staff to wear cloth masks instead of surgical masks while caring for residents, contrary to CDC guidelines. The facility lacked a policy on cloth mask use and was found noncompliant with PPE requirements.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that medical approved personal protective equipment (PPE) was worn while in a resident care area, specifically allowing a nursing assistant to wear a cloth mask instead of a surgical mask. |
Report Facts
Date of observation: Jun 2, 2020
Date of interview: Jun 3, 2020
Plan of correction submission deadline: Jun 18, 2020
Staff PPE education completion deadline: Jun 30, 2020
Audit period: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa A. DiLorenzo | Supervising Nurse Consultant | Signed letter as Supervising Nurse Consultant for Facility Licensing and Investigations Section |
| Cori Knutsen | Administrator | Administrator of Parkville Care Center addressed in the letter |
| Nursing Assistant #1 | Observed wearing cloth mask instead of surgical mask during resident care | |
| Director of Nursing | Director of Nursing | Interviewed regarding mask policy and PPE use |
Inspection Report
Monitoring
Census: 109
Capacity: 150
Deficiencies: 1
May 12, 2020
Visit Reason
The visit was a monitoring visit focused on COVID-19 infection control conducted by the Department of Public Health.
Findings
The inspection found violations related to the facility's handling of personal protective equipment (PPE) during the COVID-19 pandemic, including lack of N95 masks and improper use and storage of Tyvek suits. The facility was not provided with N95 masks and did not perform fit testing. The Director of Nursing and Administrator provided information on PPE usage and supply issues.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide N95 masks and did not perform fit testing for staff caring for COVID-19 positive residents; improper storage and use of Tyvek suits and PPE. |
Report Facts
Licensed Bed Capacity: 150
Census: 109
Tyvek suits observed: 30
Date of inspection: May 12, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cori Knutsen | Administrator | Contacted personnel and provided information during the inspection. |
| Miranda Wilmot | Director of Nursing | Interviewed regarding PPE use and facility COVID-19 units. |
| Jasmine Johnson | Infection Control Nurse | Participated in facility tour and observations of PPE use. |
Inspection Report
Monitoring
Census: 109
Capacity: 150
Deficiencies: 1
May 12, 2020
Visit Reason
The visit was an unannounced monitoring inspection conducted to assess COVID-19 infection control practices at Parkville Care Center.
Findings
The facility failed to provide staff working in COVID-19 designated areas with appropriate PPE, including N95 masks and Tyvek suits, and did not follow CDC recommendations for PPE use and fit testing, placing staff and residents at risk of infection.
Deficiencies (1)
| Description |
|---|
| Failure to provide staff working on designated COVID-19 areas with appropriate PPE and failure to utilize Tyvek suits according to CDC recommendations, resulting in risk of infection to staff and residents. |
Report Facts
Licensed Bed Capacity: 150
Census: 109
Units: 5
Tyvek suits observed: 30
Plan of Correction submission deadline: 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cori Knutsen | Administrator | Administrator interviewed and named in relation to infection control findings |
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter regarding violations and plan of correction |
| Deidre S. Gifford | Acting Commissioner | Named on official letterhead |
Inspection Report
Abbreviated Survey
Deficiencies: 1
May 12, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The facility failed to provide staff working in designated COVID-19 areas with appropriate and recommended Personal Protective Equipment (PPE), including the use of Tyvek suits and N95 masks according to CDC recommendations, potentially exposing staff and residents to infection risk.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide staff working on designated COVID-19 units with appropriate and recommended PPE, including proper use of Tyvek suits and N95 masks. | SS=E |
Report Facts
Used Tyvek suits observed: 30
Units dedicated to COVID-19 positive residents: 2
Total units in facility: 5
Date facility received N95 and KN95 masks: May 6, 2020
Inservice education completion date: May 30, 2020
Audit period: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding PPE use and facility practices on May 12, 2020. |
| Administrator | Administrator | Interviewed regarding facility COVID-19 unit setup and PPE on May 12, 2020. |
| Infection Control Nurse | Infection Control Nurse | Participated in facility tour and observations on May 12, 2020. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
May 12, 2020
Visit Reason
An unannounced visit was made to Parkville Care Center on May 12, 2020 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a COVID-19 focused survey.
Findings
The survey found that the facility was separated into five units with two units dedicated to COVID-19 positive residents. Observations noted lack of N95 masks in storage and on resident care units, use of KN95 masks by nursing staff, and improper use and storage of Tyvek suits. The Director of Nursing indicated the facility was not provided with N95 masks and fit testing was not required. Documentation showed delivery of N95 and KN95 masks on May 6, 2020, but the DON had not received the N95 masks at the time of the survey.
Deficiencies (1)
| Description |
|---|
| Failure to utilize Tyvek suits according to CDC recommendations and lack of N95 masks in storage and on resident care units. |
Report Facts
Units dedicated to COVID-19 positive residents: 2
Total units in facility: 5
Used Tyvek suits observed: 30
Date of PPE delivery: May 6, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding PPE use and facility COVID-19 unit operations |
| Administrator | Administrator | Interviewed regarding facility separation into units and PPE use |
Inspection Report
Routine
Deficiencies: 1
May 12, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The facility failed to ensure proper use of Tyvek suits according to CDC recommendations during the pandemic, with staff reusing suits across shifts despite education. Observations noted approximately thirty used Tyvek suits hanging in a room, and the Director of Nursing was unable to provide CDC guidance on one-time use of these suits.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure utilized Tyvek suits according to CDC recommendations during a pandemic to protect staff and residents from infection risk. | SS=D |
Report Facts
Used Tyvek suits observed: 30
Facility units: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding PPE use and facility infection control practices. |
| Administrator | Administrator | Interviewed during the survey regarding facility operations and infection control. |
| Infection Control Nurse | Infection Control Nurse | Participated in facility tour and observations of PPE use. |
Inspection Report
Routine
Census: 112
Capacity: 150
Deficiencies: 0
Apr 27, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found no deficiencies related to infection prevention and control practices for COVID-19 at Parkville Care Center.
Inspection Report
Routine
Deficiencies: 0
Apr 21, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found no deficiencies related to infection prevention and control practices for COVID-19 at Parkville Care Center.
Inspection Report
Plan of Correction
Deficiencies: 5
Nov 12, 2019
Visit Reason
An unannounced visit was made to Parkville Care Center on November 12, 2019 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
The report identifies multiple violations related to the care of Resident #1, including failure to implement safety interventions for suicidal ideation, failure to revise care plans after an attempted suicide, failure to monitor targeted behaviors related to antipsychotic medication, and failure to report an attempted self-injury to the state agency. The facility submitted a plan of correction addressing these deficiencies.
Deficiencies (5)
| Description |
|---|
| Failure to implement safety interventions in accordance with the plan of care regarding Resident #1's history of suicidal ideation. |
| Failure to review and revise the care plan after an attempted suicide to ensure the resident's environment was safe and secure. |
| Failure to identify and monitor Resident #1's targeted behaviors related to antipsychotic medication use. |
| Failure to report an attempted self-injury to the state agency. |
| Failure to document that Resident #1 was assessed post suicidal attempt prior to hospital transfer. |
Report Facts
Dates: Nov 12, 2019
Plan of correction submission deadline: Nov 29, 2019
Plan of correction completion date: Dec 24, 2019
Frequency of safety checks: 15
Medication dosage: 200
Blood pressure: 14394
Pulse: 95
Respirations: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed letter regarding plan of correction instructions |
| George Kingston | Administrator | Named as facility administrator and signed plan of correction |
Inspection Report
Annual Inspection
Deficiencies: 13
Mar 27, 2019
Visit Reason
Unannounced visits were made to the facility on March 24, 25, 26, and 27, 2019 by representatives of the Facility Licensing & Investigations Section for the purpose of conducting a certification survey.
Findings
The facility was found deficient in multiple areas including failure to ensure accurate documentation of advance directives, failure to notify responsible parties and physicians of injuries of unknown origin, failure to report such injuries to the state agency, failure to complete timely comprehensive assessments, inaccuracies in Minimum Data Set (MDS) coding, failure to notify or involve responsible parties in care plan conferences, failure to provide adequate nail care, failure to follow physician orders for surgical consults, improper resident positioning during meals, failure to apply splints as ordered, and failure to maintain a safe environment including secure medication storage and wheelchair maintenance.
Severity Breakdown
SS=D: 10
SS=E: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to ensure accurate documentation of residents' code status in medical records. | SS=D |
| Failure to provide appropriate notifications to responsible party and physician after identifying an injury of unknown origin. | SS=D |
| Failure to report an injury of unknown origin to the applicable state agency. | SS=D |
| Failure to conduct an investigation regarding an injury of unknown origin when staff was made aware. | SS=D |
| Failure to complete and submit a comprehensive Minimum Data Set (MDS) assessment in a timely manner. | SS=D |
| Failure to accurately code MDS assessments including level II PASRR status and insulin administration. | SS=D |
| Failure to provide documentation of initial care plan conference meeting and notification/invitation to responsible party. | SS=D |
| Failure to provide nail care to a dependent resident. | SS=D |
| Failure to apply bilateral elbow splints per physician's orders. | SS=D |
| Failure to ensure resident environment remains free of accident hazards and adequate supervision to prevent accidents, including unsecured lancets and unauthorized access to medication rooms. | SS=D |
| Failure to follow physician's order for surgical consultation and failure to ensure proper positioning and assistance during meals for residents with dysphagia. | SS=E |
| Failure to ensure a Registered Nurse assessment was completed prior to moving a resident following a fall. | SS=E |
| Failure to maintain wheelchair in good repair, including cracked armrests and taped armrest. | SS=D |
Report Facts
Deficiencies cited: 12
MDS assessment dates: 2019
Fall date: 2019
Splint application times: 4
Bruise size: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to advance directive documentation and medication cart lancet storage |
| RN #1 | Registered Nurse | Named in findings related to injury notification and bruise reporting |
| RN #3 | Registered Nurse, MDS Coordinator | Named in findings related to MDS assessment completion and care plan conference |
| RN #5 | Registered Nurse | Named in findings related to care plan conference |
| NA #1 | Nurse Aide | Named in findings related to injury reporting |
| LPN #3 | Licensed Practical Nurse | Named in findings related to injury reporting |
| MD #1 | Physician | Named in findings related to advance directive and surgical consult |
| DNS | Director of Nursing Services | Named in multiple findings related to injury reporting, MDS, care plan, and medication room access |
| LPN #8 | Licensed Practical Nurse | Named in findings related to splint application |
| NA #8 | Nurse Aide | Named in findings related to splint application |
| LPN #4 | Licensed Practical Nurse | Named in findings related to medication room access |
| Medical Records Person | Medical Records Staff | Named in findings related to surgical consult scheduling and medication room access |
| NA #2 | Nurse Aide | Named in findings related to medication room access |
| LPN #6 | Licensed Practical Nurse | Named in findings related to wheelchair maintenance |
| Maintenance Assistant #1 | Maintenance Assistant | Named in findings related to wheelchair repair |
| ADNS | Assistant Director of Nursing | Named in findings related to fall policy and medication cart lancet storage |
| NA #4 | Nurse Aide | Named in findings related to feeding assistance |
| NA #5 | Nurse Aide | Named in findings related to feeding assistance |
| Director of Therapy Services | Therapy Services Director | Named in findings related to resident positioning during meals |
| SW #1 | Social Worker | Named in findings related to care plan conference notification |
Inspection Report
Plan of Correction
Deficiencies: 11
Mar 27, 2019
Visit Reason
Unannounced visits were made to Parkville Care Center which concluded on March 27, 2019 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a certification survey.
Findings
The report details multiple violations of Connecticut State Agencies regulations related to documentation of residents' code status, mistreatment notifications, injury reporting, care planning, medication administration, and facility safety. The facility failed to ensure accurate documentation, timely reporting, and proper care in several areas, including advance directives, injury investigations, MDS submissions, and medication storage.
Deficiencies (11)
| Description |
|---|
| Failure to ensure accurate documentation of residents' code status for Residents #49 and #66. |
| Failure to provide appropriate notifications after identifying an injury of unknown origin for Resident #99. |
| Failure to conduct an investigation regarding an unknown origin injury for Resident #99. |
| Failure to ensure an injury of unknown origin was investigated and reported. |
| Failure to ensure completion and submission of Minimum Data Set (MDS) in a timely manner for Resident #1. |
| Failure to correctly code a Minimum Data Set (MDS) for Residents #49 and #66. |
| Failure to provide nail care to a dependent resident (Resident #70). |
| Failure to apply splints per physician's orders for Resident #63. |
| Failure to ensure proper positioning and/or assistance during meals for Residents #81 and #19. |
| Failure to ensure a Registered Nurse (RN) assessment was completed prior to moving a resident following a fall for Resident #19 and failure to follow physician's orders for Resident #66 and Resident #81. |
| Failure to ensure the environment remained free of hazards and/or hazards were maintained in a safe and secure manner, including storage of lancets and medication rooms. |
Report Facts
Plan of correction submission deadline: 2020
Audit period: 30
Audit start date: 2019
Resident sample size: 3
Resident sample size: 2
Resident sample size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cher Michaud | Supervising Nurse Consultant | Signed the letter and mentioned as contact for questions regarding deficiencies. |
| George Kingston | Administrator | Named as recipient of the letter and involved in facility administration. |
| Cori Knutsen | Named in letterhead and throughout the report as contact or facility representative. |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 150
Deficiencies: 6
Mar 24, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding violations of Connecticut State statutes and regulations at Parkville Care Center.
Findings
The investigation identified multiple deficiencies related to resident care, including failure to provide appropriate notifications for injuries, inadequate documentation, failure to ensure safety interventions, and issues with medication administration and care planning.
Complaint Details
The visit was complaint-related, investigating allegations of mistreatment and failure to provide appropriate care and notifications related to injuries of unknown origin and other care deficiencies.
Deficiencies (6)
| Description |
|---|
| Failure to provide appropriate notifications to responsible parties and physicians after identifying an injury of unknown origin. |
| Failure to ensure completion and submission of Minimum Data Set (MDS) assessments in a timely manner. |
| Failure to provide adequate care and supervision to prevent injuries and ensure safety. |
| Failure to maintain accurate and complete clinical documentation and care plans. |
| Failure to ensure safe medication administration and secure medication storage. |
| Failure to provide adequate staff education and supervision related to care practices. |
Report Facts
Licensed Bed Capacity: 150
Census: 127
Inspection Dates: 4
Deficiencies cited: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| George Kingston | Administrator | Named in relation to the inspection and complaint investigation. |
| Miranda Wilmot | DOO | Named in relation to the inspection and complaint investigation. |
| Cher Michaud | Supervising Nurse Consultant | Signed the important notice and correspondence related to the inspection. |
| Karen Gworek | Supervising Nurse Consultant | Signed the report submitted on 1/14/19. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Mar 11, 2019
Visit Reason
Unannounced visits were made to the facility on 3/5/19 and 3/11/19 by a representative of the facility licensing and investigation section for the purpose of conducting an investigation related to a complaint.
Findings
The facility failed to make continued attempts to reach a responsible party and/or take action when a change in condition was identified for Resident #1. Additionally, the facility failed to obtain ordered parathyroid hormone bloodwork, ensure intake and output documentation, provide consistent social services support, and maintain accurate documentation of tube feeding flushes.
Complaint Details
The investigation was triggered by a complaint regarding failure to notify responsible parties of changes in condition and failure to provide adequate care and social services to Resident #1.
Severity Breakdown
SS=D: 3
SS=B: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to make continued attempts to reach responsible party and/or take action when a change in condition was identified for Resident #1. | SS=D |
| Failed to obtain parathyroid hormone levels quarterly as ordered and failed to ensure intake and output documentation per facility policy for Resident #1. | SS=D |
| Failed to provide consistent medically-related social services support for Resident #1. | SS=D |
| Failed to safeguard resident-identifiable information and maintain complete, accurate, and systematically organized medical records, including accurate documentation of tube feeding flushes for Resident #1. | SS=B |
Report Facts
Blood Urea Nitrogen (BUN) level: 168
Intake and Output documentation missing days: 19
Water flush volume: 150
Missing documentation days: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| APRN #1 | Advanced Practice Registered Nurse | Interviewed regarding attempts to contact Resident #1's conservator and family about condition changes. |
| SW #1 | Social Worker | Interviewed about social service documentation and handling of returned certified letter to conservator. |
| Director of Nurses (DON) | Director of Nurses | Interviewed about notification attempts to responsible parties and facility procedures. |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed about sending certified letter to conservator and communication issues. |
| LPN #3 | Licensed Practical Nurse | Interviewed about administration and documentation of water flushes via feeding tube. |
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