Park Place

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Oct 22, 2021

  Based on interviews, review of Resident Identifier (RI) #1's medical records, Potter and Perry's FUNDAMENTALS OF NURSING NINTH EDITION, and the facility's policy titled, Medication Errors, the facility failed to ensure RI #1, a kidney transplant resident taking anti-rejection medication, received [MEDICATION(S)] Anhydrous (an anti-rejection medication) from [DATE]-[DATE]. RI #1 was admitted to the facility on [DATE] from a local hospital. The transfer medication list from the hospital, listed [MEDICATION(S)] Anhydrous 0. 5 mg (milligrams) three tablets twice a day as a medication to be continued. […]

• Immediate jeopardy, isolatedF842Oct 22, 2021

  Based on interviews and review of Resident Identifier (RI) #1's medical records, Potter and Perry's FUNDAMENTALS OF NURSING NINTH EDITION, the facility's policy titled, New/Re-Admit physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of this deficient practice, RI #1 did not receive the ordered medication during his/her stay at the facility from 5/21/2021-6/01/2021 and suffered a significant medication error. RI #1 was admitted to the facility on [DATE] from a local hospital. The transfer medication list from the hospital listed [MEDICATION(S)] Anhydrous 0.5 mg three tablets twice a day as a medication to be continued. […]

• No harm, potential for more than minimal, widespreadF868Apr 6, 2022

  Based on interviews and review of a document titled, [Facility Name] QAPI [Quality Assurance Performance Improvement] Plan, the facility failed to ensure the QAPI committee was composed of the required committee members. Specifically, the facility failed to provide evidence that a Medical Director (MD) or designee participated as a required QAPI committee member at least quarterly. Findings include: A review of the [Facility Name] QAPI Plan, dated 02/2017, revealed that QAPI membership included the MD, Administrator, and the Director of Nursing at a minimum. A review of the facility's QAPI Meeting sign-in sheets revealed an MD had not signed as present during a meeting since 07/16/2021. […]

• No harm, potential for more than minimal, isolatedF637Apr 6, 2022

  Based on record review, interviews, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a comprehensive Significant Change in Status Minimum Data Set (MDS) was completed within fourteen days of Resident Identifier (RI) #55's discharge from hospice services. This affected RI #55, one of one resident reviewed for hospice services. Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual revealed the following: .CH (Chapter) 3: MDS Items [A] . […]

• No harm, potential for more than minimal, isolatedF758Apr 6, 2022

  Based on interviews, record review, and review of a policy titled, [CONDITION(S)] Medication Use, the facility failed to attempt a gradual dose reduction (GDR) for Resident Identifier (RI) #90, one of five residents reviewed for unnecessary medications. Findings included: A review of the [CONDITION(S)] Medication Use policy, dated 12/01/2007, revealed, .Facility should ensure that the ordering physician reviews the medication plan and considers a GDR of [CONDITION(S)] medications for the purpose of finding the lowest effective dose unless a GDR is clinically contraindicated. Physician should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior . […]