Inspection Reports for
Scottish Rite Park Health Care Center

The facility failed to ensure Resident #1 received a safe transfer, resulting in severe, life-threatening injuries from a fall off a mechanical lift. Staff did not properly secure sling loops during the transfer, causing the resident to fall. The facility provided staff education and hands-on training prior to the survey.

Complaint #3000792-C resulted in a deficiency. Facility reported incident #3000864-I resulted in a deficiency.

The facility failed to ensure Resident #1 received a safe transfer using the full-body mechanical lift, resulting in a fall and life-threatening injuries including brain bleeds, broken neck, collarbone, and femur fractures. The facility corrected the noncompliance prior to the survey by providing staff education and hands-on training on safe lift operation.

The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted, resulting in certification effective July 2, 2025.

The facility was found deficient for failing to complete and transmit a resident's Minimum Data Set (MDS) discharge assessment within the required timeframe for one resident (Resident #14). Additionally, the facility failed to follow the care plan related to the use of a left wrist splint for another resident (Resident #28), including lack of documentation and inconsistent application of the splint.

The facility failed to complete and transmit a resident's discharge MDS assessment within the required timeframe for one of fifteen residents reviewed. Additionally, the facility failed to follow the care plan related to splint application for one of thirteen residents reviewed, with documentation and compliance issues noted.

All deficiencies were corrected and the facility is in substantial compliance effective January 24, 2025.

The visit was complaint-related due to a fall incident involving Resident #1 who was not assisted with a gait belt as required by the Care Plan. The complaint was substantiated by findings of staff interviews and record reviews indicating failure to follow safety protocols and inadequate staff training.

The facility failed to ensure proper use of gait belts during resident transfers, resulting in a fall and fracture of Resident #1's left ankle. Staff interviews and record reviews revealed inadequate staff training, lack of orientation checklists, and inconsistent adherence to safety protocols. The facility provided gait belts post-incident and initiated staff education.

The facility failed to ensure staff used a gait belt for Resident #1 during transfers and ambulation, despite the resident's risk for falls and care needs. Staff interviews confirmed inconsistent gait belt use, and no Care Plan policy was found. Resident #1 fell and fractured her left ankle when a gait belt was not used.

The facility was found to be in substantial compliance as of August 12, 2024. The report details a past incident where a resident was not safely transferred using a mechanical standing lift, resulting in a fall and neck discomfort. The facility has since implemented training and policies to ensure safe transfers.

Complaint #120103-C was substantiated related to deficiencies in MDS assessments and resident care.

The facility was found deficient in completing timely and accurate quarterly Minimum Data Set (MDS) assessments for multiple residents, developing and implementing comprehensive care plans reflecting residents' needs such as oxygen use, and ensuring safe use of assistive devices like the EZ stand lift. Resident #2 experienced multiple falls related to improper use and supervision during transfers with the EZ stand lift, resulting in a fracture. The facility lacked policies and staff competency checks for EZ stand use.

The complaint investigation revealed substantiated findings that the facility failed to complete timely MDS assessments, failed to develop adequate care plans, and failed to safely use an EZ stand mechanical lift, resulting in two falls and a fracture for Resident #2. The resident reported fear of using the EZ stand due to weakness and prior falls. The facility did not report the fall with fracture to the state as required.

The facility failed to complete and transmit residents' minimum data set assessments timely for 4 of 12 residents sampled, failed to develop and implement a comprehensive care plan for oxygen use for one resident, and failed to safely use an EZ stand mechanical lift resulting in two falls and a fracture for one resident. The facility lacked policies and competency checklists for MDS assessments, care plans, and EZ stand use.

Resident #2 fell when the EZ stand strap broke, resulting in a displaced fracture of the right humerus. The facility did not report this major injury fall to the state within the required timeframe. Staff interviews and records confirmed the fall and injury, and the resident expressed fear of using the EZ stand due to weakness and prior falls.

No regulatory insufficiencies were cited.

Complaint investigation for incidents #117395-I and #116117-I; facility found in substantial compliance.

The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

The facility was certified in compliance effective May 11, 2023, based on acceptance of a credible allegation of compliance and plan of correction.

The facility was found to have expired food items in the kitchen, indicating failure to ensure food safety requirements related to procurement, storage, preparation, and serving of food. The dietary staff failed to prevent serving expired food items, posing a risk of contamination and food-borne illness.

The facility failed to ensure expired food items were not served, as multiple expired food products were found during the kitchen tour. Staff interviews and policy review confirmed expectations for regular checks of food expiration dates were not adequately followed.

The facility was certified in compliance effective February 16, 2022, based on acceptance of a credible allegation of compliance and plan of correction.

The facility failed to ensure accurate assessments for 2 of 3 residents reviewed regarding unnecessary medications, specifically discrepancies in documenting depression diagnoses in Minimum Data Set (MDS) assessments despite residents receiving antidepressants.

No regulatory insufficiencies were cited. There were no deficiencies cited during the onsite infection control survey.

The visit was complaint-related, investigating allegations of abuse and improper restraint use involving Resident #1. The complaint was substantiated as the facility failed to prevent improper restraint use and failed to report incidents properly. The Chief Nursing Officer (CNO) acknowledged poor nursing judgment and failure to report the incident to the Department of Inspections and Appeals.

The facility failed to ensure residents were treated with respect and dignity, specifically regarding the improper use of physical restraints on Resident #1. The facility also failed to properly report incidents of abuse and ensure staff followed abuse reporting protocols. Staff showed poor nursing judgment in the use of restraints, and the facility did not take adequate corrective actions during the investigation period.

The facility failed to ensure staff displayed respect for residents and improperly restrained Resident #1 by fastening a gait belt to a dining chair, restricting the resident's movement without medical justification. The Chief Nursing Officer acknowledged poor nursing judgment in this intervention.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

The facility failed to ensure availability of staff certified in CPR for each shift, failed to serve proper puree diet portions for a resident, and failed to provide safe and proper sanitization while serving food. Deficiencies were identified related to CPR certification, menu preparation and portion sizes, and food safety practices.