Park Place Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF684May 5, 2025

  Based on interview and record review, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 9 residents (Resident #1) reviewed for quality of care. 1. The facility failed to follow up with a cardiologist appointment on 2/25/25 for Resident #1 for 36 days, from 2/25/25 to 4/1/25. 2. The facility failed to ensure Resident #1 received a vascular surgeon referral when the order was given on 02/12/25, which resulted in the development of gas gangrene (rare but highly lethal and potentially life-threatening bacterial infection that destroys muscle tissue, blood cells, and blood vessels producing a gas that causes tissue death and a foul smell) and an above-the-knee amputation (surgical removal) of his right leg on… […]

• Actual harm, isolatedF791Apr 4, 2026

  Based on interview, and record review, the facility failed to provide or obtain necessary emergency dental services for 1 of 9 residents reviewed for dental services (Resident #1).The facility failed to timely complete and follow up on a dental referral after becoming aware of Resident #1's dental concerns on 3/3/26. The referral was not submitted until 3/12/26, resulting in the resident developing right-sided facial swelling, pain, and infection, requiring transfer to the emergency room on 3/12/26.This failure placed residents at risk for delayed dental treatment, increased pain, infection, and decline in condition.Findings included:Record review of an admission record dated 04/03/26 indicated Resident #1 was a [AGE] year-old male who initially admitted to the facility on [DATE] and… […]

• Actual harm, isolatedF600Nov 20, 2025

  Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse for 1 of 4 residents reviewed for abuse. (Residents #1)The facility failed to ensure Resident #1 was free from physical abuse when on 05/02/25 Resident #2 grabbed Resident #1's shirt around the neck, stretching the fabric, and bit her hand. Resident #1 had a visible bite mark to the back of the left hand and redness to the chest. This failure could place residents at risk for emotional distress, fear, decreased quality of life, and further abuse.Findings included:Record review of a face sheet dated 11/20/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. […]

• No harm, potential for more than minimal, patternF755Jun 30, 2026

  Based on interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 6 of 7 medication carts reviewed for pharmacy services [1st Floor MA Cart, 1st Floor Nurse West/North (Odd) Cart, 2nd Floor MA West/North (Odd) Cart, 2nd Floor MA East/North (Even) Cart, 2nd Floor Nurse West/North (Odd) Cart, 2nd Floor East/North (Even) Cart]). […]

• No harm, potential for more than minimal, patternF812Jun 30, 2026

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 facility kitchens.The facility failed to ensure 3 cans of beets and 1 box of soybean frying shortening were not on the pantry floor.The facility failed to ensure stainless steel steam table pans were not stacked wetThe facility failed to ensure DA A did not hand dry items placed on the drain rack at the 3-compartment sink to air dryThe facility failed to ensure the bulk sugar bin did not have a scoop laying inside the product.These failures could place residents who ate food from the kitchen at risk of foodborne illness.Findings included:During observations and interviews on 06/28/2026 of the kitchen the following was noted:*at 8:15 AM in… […]