Complete Care at Park Place LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Park Place LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Dec 7, 2022

  Based on observations, record reviews, interviews, and policy review, the facility failed to ensure that one of one resident (Resident (R) 23) reviewed for tracheostomy (trach) care out of a total sample of 20 residents was provided necessary suctioning of the airway, had the necessary supplies at the bedside in the event of a life-threatening emergency, and failed to train staff on appropriate emergency tracheostomy care in the event that a resident's airway was compromised, which placed residents with a tracheostomy at increased likelihood of serious harm or death and resulted in harm to R23 who was admitted to the hospital with diagnoses of pneumonia due to an infectious organism, AMS (altered mental status), SOB (shortness of breath), rigors (fever causing severe chills and shaking),… […]

• Actual harm, isolatedF710Dec 7, 2022

  Based on record review, interviews, and policy review, the facility failed to ensure the physician clarified orders for suctioning and emergency tracheostomy care for one of one resident (Resident (R) 23) with a tracheostomy (a surgical opening into the windpipe for breathing) out of a total sample of 20 residents. These failures resulted in harm to R23 who was admitted to the hospital with diagnoses of pneumonia due to an infectious organism, AMS (altered mental status), SOB (shortness of breath), rigors (fever causing severe chills and shaking), respiratory distress, increasingly thick trach secretions, and sepsis (injury to tissues and organs due to infection). […]

• No harm, potential for more than minimal, widespreadF880Mar 13, 2026

  Based on observation, interviews, and facility document review, the facility failed to ensure personal protective equipment (PPE) was worn by laundry staff in one of one laundry rooms while sorting soiled resident clothing and bed linens. This had the potential to infect the staff and/or residents with pathogens which could potentially lead to the development of infectious diseases.Findings include:During an observation conducted with the Infection Preventionist (IP) on 03/13/26 at 9:42 AM, upon entrance to the laundry room, the Laundry Aide was observed reaching into a soiled container of linens and loading them into the washing machine. The Laundry Aide wore disposable gloves but did not wear a protective gown. […]

• No harm, potential for more than minimal, patternF584Mar 13, 2026

  Based on observation, interview, and document review, the facility failed to maintain a safe, clean, comfortable, and homelike environment on the memory care unit. Specifically, the floor in the dining/activity area was observed to be sticky. Additionally, a large table surface was visibly dirty. The sticky floor posed a potential risk for residents who ambulate, as it could contribute to loss of balance of falls. The unclean condition of the table had the potential to attract pests. Findings include:During an observation conducted on 03/10/26 at 10:35 AM of the memory care unit's main dining/activity room, there were multiple staff and residents in the area participating in activities. The floor was observed to be dull and sticky. […]

• No harm, potential for more than minimal, patternF695Aug 30, 2024

  Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow a physician's order for a resident who required a continuous positive airway pressure (C-PAP) machine at night. This deficient practice was identified for one (1) of two (2) residents reviewed for Respiratory Care (Resident #33), and was evidenced by the following: During the initial tour of the facility on 8/22/24 at 09:35 AM, the surveyor observed an oxygen concentrator near Resident #33's bed. At that time, the surveyor did not observe a C-PAP machine (delivers oxygen via a mask while asleep) in the resident's room. […]