Park Terrace Health Campus

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF600Jan 11, 2024

  Based on interviews, record reviews, document reviews, and facility policy review, it was determined the facility failed to ensure three (3) (Residents #39, #177, and #178) of five (5) sampled residents reviewed for abuse, were from abuse. On 08/01/2021, Resident #179 physically abused Resident #39 when the resident did not respond to Resident #179's command. On 05/09/2023, Resident #176 pulled Resident #177 from their bed. On 09/04/2022, a staff member took an unauthorized photo of Resident #178 and showed the picture to other staff. Findings include: A review of the facility policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, revised on 08/29/2019, revealed, 3. […]

• No harm, potential for more than minimal, isolatedF677Jul 19, 2025

  Based on interview and record review, the facility failed to provide showers to residents who required assistance with their activities of daily living (ADLs), for 2 of 13 residents sampled for ADL care (Resident (R)96 and R100).The findings include:1. Review of the Resident Face Sheet for R96 revealed the facility admitted the resident on 08/09/2024, with a diagnosis of end stage renal disease. Further review revealed the facility discharged R96 on 09/15/2024. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/15/2024, revealed the facility assessed R96 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. […]

• No harm, potential for more than minimal, isolatedF759Jul 19, 2025

  Based on observation, interview, record review, facility policy review, and review of the insulin pen instruction manual, the facility failed to ensure a medication error rate was not 5 percent (%) or greater for 1 of 4 residents observed during the medication administration task, (Resident (R)89).The findings include:Review of the facility policy titled, Medication Administration- General Guidelines, revised 11/2018, revealed medication were to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. […]

• No harm, potential for more than minimal, isolatedF554Jan 11, 2024

  Based on observations, interviews, record reviews, and review of the facility policy, it was determined the facility failed to assess two(2) (Resident #15 and Resident #19) of eighteen (18) sampled residents for the resident's ability to self-administer their medications. Findings include: A review of the facility policy titled, Medication Administration-General Guidelines, revised in November 2018, revealed 13. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 1. A review of Resident #15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/26/2023, revealed the facility readmitted Resident #15 on 11/13/2021. […]

• No harm, potential for more than minimal, isolatedF610Jan 11, 2024

  Based on interview, record reviews, document review, and facility policy review, it was determined the facility failed to have evidence to indicate an allegation of abuse which involved two residents, Resident #39 and Resident #179, of five (5) sampled residents reviewed for abuse prohibition, was thoroughly investigated. Findings include: A review of the facility policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, revised on 08/29/2019, revealed f. Investigation i. The Executive Director is accountable for investigating and reporting. ii. Exercising caution in handling evidence that could be used in a criminal investigation iii. Investigating different types of allegation violations iv. […]