Park Center Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Park Center Healthcare and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Oct 1, 2021

  Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, The Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20, review of CMS Memo QSO 20-38 revised 09/10/21, Nursing Home Guidance from the Centers for Disease Control (CDC), record review, review of a facility COVID-19 timeline and staff statement, review of the county community COVID-19 transmission rate, review of staff time sheets, review of staff screening forms, review of resident and staff COVID-19 laboratory results and rapid point of care (POC) test results, review of facility audits, review of resident and staff vaccination logs, staff interviews, interview with the local health… […]

• Immediate jeopardy, isolatedF600Oct 5, 2023

  Based on medical record review, review of a self-reported incident (SRI), review of the local police report, review of the facility investigation, policy review, and resident and staff interviews, the facility failed to ensure residents were free from physical abuse by a staff member. This resulted in Immediate Jeopardy and serious psychosocial harm for Resident #72, when Licensed Practical Nurse (LPN) #315 pushed Resident #72's head into a wall and physically restrained Resident #72 with her hands around Resident #72's throat in response to aggressive behaviors exhibited by Resident #72 with resultant gasping for air, trying to say she could not breath, fear for her safety in the facility and subsequent sleep disturbance requiring the prescription of a hypnotic sleep medication and… […]

• Actual harm, isolatedF686May 18, 2021

  Based on observation, interview, review of the facility policy and procedure for skin management, and record review the facility failed to implement a comprehensive and effective pressure ulcer prevention program to prevent and identify pressure ulcers in a timely manner for Resident #9. Actual Harm occurred on 06/02/20 when Resident #9, who required extensive assist of one person with bed mobility and extensive assist of two persons with transfers was found to have a Stage three (full thickness tissue loss, with subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) pressure ulcer to her right heel. In addition, the facility failed to timely complete a wound assessment upon discovery of a new wound for Resident #56. […]

• No harm, potential for more than minimal, widespreadF812Sep 11, 2024

  Based on observation, interview and policy review the facility failed to ensure food was stored and served in a manner to prevent contamination and food born illness. This had the potential to affect all 92 residents residing in the facility. There were no residents identified as having a nothing by mouth diet. The facility census was 92. Findings include: On 09/09/24 at 10:02 A.M. a tour of the kitchen revealed in the small upright refrigerator a two-quart plastic container of chicken noodle soup that was half full and not dated as to when it was stored. There were slices of bologna wrapped in plastic with no date. There was sliced ham 48 oz open and undated. The refrigerator also contained eight hard- boiled eggs wrapped in plastic and undated. […]

• No harm, potential for more than minimal, widespreadF679Apr 29, 2024

  Based on observation, interview, and record review the facility did not ensure all residents were provided therapeutic activities as scheduled and in the evenings to meet their needs and preferences. This affected all 92 residents residing in the facility. The facility census was 92. Findings include: Record review of the facility activity calendar dated November 2023 revealed coffee social took place every day at 10:00 A.M., one-to-one visits every day and there were no activities scheduled after 2:30 P.M. except one day on 11/24/23 there was black Friday bingo at 3:00 P.M. There were no religious services scheduled for the month. There was no activity calendar specific to the residents residing on the secured behavior unit (unit 3A). […]