Park Rose Care Center

In the surveyor’s words

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

• Actual harm, isolatedF693Sep 18, 2024

  Based on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was managed in accordance with provider's orders and professional standards of practice to ensure correct placement prior to administering medications, manage the amount of fluids received and implement as needed (PRN) provider's orders for 4 of 4 sampled residents (Residents 33, 73, 77, and 7) reviewed for enteral nutrition. […]

• Actual harm, isolatedF686Feb 8, 2024

  Based on interview and record review, the facility failed to address a new skin pressure injury, failed to notify the provider timely and failed to implement wound treatment orders timely for 1 of 5 sampled residents (Resident 1) reviewed for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Resident 1 experienced harm when they developed a facility acquired pressure ulcer which deteriorated and became infected. This failure placed other residents at risk for development and/or worsening of wounds, infection, and medical complications. Findings included . Review of the facility's policy titled, Skin at Risk Overview, revised on 04/2018, showed 4. […]

• Actual harm, isolatedF760Jan 24, 2024

  Based on interview and record review, the facility failed to ensure residents received medications as ordered and notify the provider and resident/resident representative timely of missed medication for 1 of 7 sampled residents (Resident 1) reviewed for significant medication errors. This failure resulted in harm to Resident 1 who experienced a sudden decline in condition that included the inability to swallow and being in an unresponsive state. This failure prevented Resident 1's decision maker from being fully informed of Resident 1's change in condition prior to a transition onto Hospice Service. […]

• Actual harm, isolatedF686Aug 7, 2023

  Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent the development of avoidable pressure injuries (PIs) for 1 of 3 residents (Resident 1) reviewed, when the facility failed to implement interventions and to re-evaluate the interventions or the resident's plan of care as multiple PIs developed. These failures caused harm to Resident 1 who developed multiple avoidable full thickness pressure injuries. Findings included . Review of the facility's Skin at Risk Program Overview policy, revised 04/2018, showed the facility would ensure that residents who entered the facility without a significant wound, would not develop wounds unless their clinical condition demonstrated the wound was unavoidable. […]

• No harm, potential for more than minimal, widespreadF865Jul 2, 2025

  Based on interview and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, and a pattern of deficiencies that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care. Findings included . […]