Park Place Transitional Care and Rehabilitation

In the surveyor’s words

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

• Actual harm, patternF686Apr 27, 2023

  Based on observation, interview, and record review, facility staff failed to identify, prevent, and treat pressure ulcers which led to the development of two Stage IV pressure ulcers which required hospitalization , and wound clinic management for 1(#4); and failed to identify, prevent, and treat pressure ulcers which led to the development of 3 Stage II, and 1 Stage III, pressure ulcers, for 2 (#s 98 and 194) of 5 sampled residents. Findings include: 1. During an observation on 4/24/23 at 3:36 p.m.,., resident #4 was lying on his bed with an air mattress. […]

• Actual harm, patternF689May 12, 2022

  Based on observation, interview, and record review the facility failed to prevent and provide timely treatment for a resident who fell , was not sent for treatment for several hours, and was found to have sustained multiple fractures, for 1 (#5), and failed to provide supervision of a resident to prevent a fall that resulted in head and facial bruising for 1 (#77) of 4 sampled residents. The facility failed to provide supervision during meals for 2 (#28 and #73) out of 2 sampled residents who were at risk for aspiration. Findings include: 1. During an observation and interview on 5/10/22 at 8:28 a.m., resident #5 was observed in bed on her back with a sheet pulled over her. […]

• Actual harm, isolatedF689Apr 9, 2026

  Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accidents and hazards, failed to provide supervision necessary to prevent accidents related to falls, and failed to thoroughly investigate (including interviewing resident #129) and identify the direct root causes of falls for future fall prevention, for 4 (#s 5, 45, 156, and 160) of 29 sampled residents, and the falls resulted in resident #160 sustaining a hip fracture, resident #45 had a closed head injury, and #156 had a laceration above the eye; and the facility failed to ensure interventions and safety assessments were in place for a resident who was smoking on facility property, and who kept his smoking materials, and the facility reported they were a non-smoking… […]

• Actual harm, isolatedF686Apr 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure a resident admitted without a pressure ulcer did not develop a pressure ulcer for 1 (#10) of 2 sampled residents with pressure ulcers. Resident #10 was admitted with intact skin on the sacrum and developed a Stage III pressure ulcer which progressed to a Stage IV with healing not achievable. The resident did have refusals of care, and the facility implemented interventions for wound prevention, but failed to identify the wound timely and prevent further deterioration or infection, of the wound, and implement and monitor sufficient intervetnions for healing, or resolve the resident's concerns with refusals and pain management which hindered wount healing. […]

• Actual harm, isolatedF692Apr 25, 2024

  Based on observation, interview, and record review, the facility failed to identify a discrepancy in weight recordings which would have identified a severe 16% weight loss in two weeks, for 1 (#40) of 1 dialysis resident sampled for weight loss. Findings include: Review of resident #40's Dialysis Communication Records, dated 3/18/24 - 4/3/24, showed an average of 2.06 lbs. of fluid removal at each dialysis treatment. The resident never had body or fluid weight gain between dialysis treatments, instead each pre-dialysis treatment record showed a consistently downward trending weight loss of one to four pounds. This loss of body weight represented a severe 16.27% weight loss in two weeks: - 3/18/24 pre-dialysis weight 205.48 lbs. Post dialysis weight was 200.6 lbs. […]