Park Lane Post Acute LLC

In the surveyor’s words

From the most serious findings on record at Park Lane Post Acute LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF642Apr 19, 2024

  Based on review of clinical records and Minimum Data Set (MDS-mandated assessments of a resident's abilities and care needs) assessments, and a staff interview, it was determined that the facility failed to timely certify the completion of the MDS assessments for nine of nine sampled residents (Residents 6, 40, 42, 50, 57, 65, 76, 77, and Resident 99). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated [DATE], indicated that the MDS Completion Date must be no later than 14 days after the Assessment Reference Date. Review of Resident 6's progress note of [DATE], revealed that resident was discharged to home. […]

• No harm, potential for more than minimal, widespreadF880Apr 19, 2024

  Based upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to ensure enhanced barrier precautions were in place for residents requiring enhanced barrier precautions for three of three reviewed (Residents 50, 212, and 213). Findings include: Review of facility policy and procedure titled Enhanced Barrier Precautions, revised March 26, 2024, revealed Enhanced Barrier Precautions (EBP) expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of multidrug resistant organism (MDROs) to staff hands and clothing. […]

• No harm, potential for more than minimal, patternF692May 16, 2025

  Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to follow physician orders and adequately monitor significant weight changes for three of eight residents reviewed for nutrition (Residents 18, 36 and 37). Findings include: Review of facility policy, Weight and Weight Change Management, last revised date unknown, revealed: Resident weights will be obtained to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. Each resident will be weighed monthly or more frequently as deemed necessary by physician orders, Dietician, or IDT (interdisciplinary team) recommendation. […]

• No harm, potential for more than minimal, patternF636Apr 19, 2024

  Based on review of the Resident Assessment Instrument User's Manual, clinical record review and staff interview, it was determined that the facility failed to ensure that the comprehensive Minimum Data Set assessments were completed in the required time frame for five of 12 residents reviewed (Residents 27, 166, 212, 214, 262) Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a comprehensive admission MDS assessment was to be completed no later than 14 days following admission and an annual assessment not less than once every 12 months. […]

• No harm, potential for more than minimal, patternF638Apr 19, 2024

  Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interviews, it was determined that the facility failed to complete a quarterly Minimum Data Set assessments timely for four of 12 residents reviewed (Residentsv 5, 22, 50, and 211 ). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions for completing Minimum Data Set (MDS- assessments (mandated assessments of residents' abilities and care needs), dated October 2019, indicated that a quarterly assessment was to be completed within 92 days of the previous assessment's (any type) reference date. […]