Inspection Reports for
The Villa at Parkridge

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to immediately assess and notify the physician and responsible party of a fall with major injury for Resident 3, resulting in delayed notification and incomplete assessment.

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility: facility failed to address repeated concerns related to food palatability, grievance resolutions, evening snacks, and call light response times.

F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances: failed to make prompt efforts to resolve grievances for one resident regarding missing clothing items.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: failed to revise care plans for two residents after significant changes in condition or preferences.

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: failed to provide necessary grooming and activities of daily living assistance to two residents, resulting in unmet care needs and potential embarrassment.

F 0692 Provide enough food/fluids to maintain a resident's health: failed to honor preferences for weight management for one resident and prevent weight loss for another, with inadequate implementation of nutritional interventions.

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: failed to maintain sufficient staff to meet resident needs timely, resulting in long call light response times and unmet needs.

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: failed to provide palatable food products and maintain proper food temperatures, resulting in decreased resident food acceptance and nutritional decline.

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility: facility failed to address repeated concerns related to food palatability, grievance resolutions, evening snacks, and call light response.

F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances: failed to make prompt efforts to resolve grievances for one resident regarding missing clothing items.

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment: failed to assess bed bolsters as potential restraints for two residents; bolsters prevented residents from getting up independently and no restraint assessments were documented.

F 0637 Assess the resident when there is a significant change in condition: failed to complete a significant change Minimum Data Set assessment timely for one resident.

F 0641 Ensure each resident receives an accurate assessment: failed to ensure Minimum Data Set assessments were completed accurately for six residents, including inaccurate coding of vaccination status, gradual dose reduction, restraint use, and diagnoses.

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: failed to develop and implement comprehensive care plans for four residents, including lack of interventions for alternating pressure mattress use, dialysis access site, behavioral interventions, and call light accessibility.

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: failed to provide necessary care to assist two residents with grooming and activities of daily living, resulting in residents not receiving needed care and potential for embarrassment and humiliation.

F 0679 Provide activities to meet all resident's needs: failed to provide meaningful, individualized activities to one resident, resulting in potential for depression, boredom, and feelings of lack of self-worth.

F 0692 Provide enough food/fluids to maintain a resident's health: failed to honor preferences for weight management for one resident and prevent weight loss for another; inadequate implementation of nutritional care plans and monitoring.

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services: failed to ensure assessment and monitoring of a dialysis access site and updated care plans for one resident; orders discontinued and not reimplemented after hospital stay.

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: failed to maintain sufficient staff to meet residents' needs timely for three residents and Resident Council; call light response times were unreasonably long and staff were observed shutting off call lights without providing care.

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life: failed to provide medically related social services for one resident with a guardian who refused care and was dissatisfied with facility conditions; lack of mental capacity reassessment and advocacy.

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: failed to ensure safe storage and administration of medications for one resident resulting in a medication error where a dose of Lithium was not administered.

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: failed to provide palatable food products and maintain safe food temperatures; multiple residents reported poor food quality and substitutions that did not meet dietary needs; food trays were transported in non-insulated carts resulting in unsafe temperatures.

F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options: failed to accurately honor gluten free diet preferences for one resident who was regularly served hot dogs and hamburgers instead of appropriate meat options.

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services: failed to ensure collaboration of care and communication with the hospice provider for one resident; hospice visit notes were lacking in the medical record and care plan.

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: failed to administer a pneumococcal immunization per consent for one resident despite consent given by Durable Power of Attorney.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: Resident #101 was burned by hot noodles served at unsafe temperature causing second-degree burns to abdomen, groin, and right inner thigh with open wounds and risk of infection.

F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances: the facility failed to notify Resident #2 of the resolutions to grievances submitted on 07/02/2024 and 07/08/2024.

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility: the facility failed to ensure grievances were promptly documented, investigated, tracked and resolved, resulting in resident frustration and feelings of being ignored.

F 0641 Ensure each resident receives an accurate assessment: the facility failed to ensure accurate coding on the Minimum Data Set (MDS) assessment for three residents, resulting in potential for inaccurate care plans and unmet care needs.

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities: the facility failed to follow-up with OBRA for one resident, resulting in potential for mismanaged mental health services.

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to ensure resident preferences were included in the plan of care for one resident, resulting in potential for anxiety and unmet preferences.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to revise a fall care plan after multiple falls for one resident, resulting in potential for additional falls.

F 0658 Ensure services provided by the nursing facility meet professional standards of quality: the facility failed to prime an insulin pen per manufacturer guidelines for one resident, resulting in potential for medication errors and adverse effects.

F 0687 Provide appropriate foot care: the facility failed to properly assess and follow podiatry services orders for one resident, resulting in resident frustration, development of long thick brittle toenails, pain, skin breakdown and delay in needed treatment.

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: the facility failed to effectively clean and maintain the physical plant affecting 123 residents, resulting in increased likelihood for cross-contamination, bacterial harborage, and reduced illumination.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; the facility failed to coordinate care plans for residents #8 and #97 regarding scheduled showers and resident independence.

F 0679 Provide activities to meet all resident's needs; the facility failed to meet individualized activity needs for Resident #67, resulting in potential boredom and decreased quality of life.

F 0684 Provide appropriate treatment and care according to orders; the facility failed to assess and monitor wound dressings for Resident #120, resulting in potential for wound infection.

F 0759 Ensure medication error rates are not 5 percent or greater; the facility had a medication error rate of 23.68% with errors including crushing medications that should not be crushed, improper administration of eye drops, and failure to remove lidocaine patches timely.

F 0679 Provide activities to meet all resident's needs: Resident #67 was not offered outdoor activities despite preferences and was unable to go outside by himself.

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: Resident #120's wound dressings were not properly monitored, resulting in maggot infestation and lack of instructions to keep Unna boots dry.

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable: The facility failed to provide backflow protection devices on two hoses connected to floor drains, risking contamination of the domestic water supply.

F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. The facility failed to promptly resolve grievances for residents regarding missing items, call light response, and cold food concerns.