Park View Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF684Sep 4, 2025

  Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 resident's reviewed (Resident #1). The facility reported a census of 43 residents. Resident #1 had wounds that were deteriorating. The resident was seen in the wound center. The facility sent the assessment of the wound in a fax to the PCP on 8/21/25 and wrote the resident would be seen in the wound center 8/22/25. The PCP replied okay. The PCP was not the wound center provider. The resident did not have an appointment on 8/22/25. The facility did not follow up until 8/27/25 with an assessment. The fax notified the wound center physician that the wound deteriorated and had a foul odor. […]

• Actual harm, isolatedF689Sep 4, 2025

  Based on observation, record review, and staff interview, the facility failed to ensure a resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident #2). Resident #1 fell on 7/10/25 fracturing his right elbow that would require surgical repair, and a laceration near his right eye requiring 7 sutures. The resident had a pressure alarm that did not sound to alert staff the resident was getting up without assistance. Staff failed to determine why the alarm did not sound. On 7/11/25 the resident fell again fracturing his left elbow, also requiring surgical repair. The resident's pressure alarm again failed to sound to alert staff the resident was getting up. The facility reported a census of 43 residents. […]

• No harm, potential for more than minimal, patternF755Jun 10, 2026

  Based on record review and staff interviews, the facility failed to ensure that only licensed staff administered medications. Additionally, the facility failed to ensure that narcotics were counted only by qualified personnel authorized to manage controlled substances, and that licensed nursing staff completed the shift-to-shift narcotic count together. These failures allowed an unlicensed staff member (CNA) to attempt medication administration and perform narcotic counts, both beyond their scope of practice. The facility reported a census of 42 residents. Findings include: 1. During an interview on 6/10/26 at 10:23 AM, Staff B, CNA, stated that agency nurse Staff C, Licensed Practical Nurse (LPN), asked if she attended nursing school. […]

• No harm, potential for more than minimal, patternF761Jun 10, 2026

  Based on staff interviews, the facility failed to ensure that medication cart keys were secured and handled exclusively by qualified personnel, allowing a Certified Nursing Assistant (CNA), who is unauthorized to manage controlled substances, to possess the keys and conduct narcotic counts. The facility reported a census of 42 residents. Findings Include: During an interview on 6/10/26 at 10:23 AM, Staff B, CNA, admitted she performed narcotic counts with Staff C, Licensed Practical Nurse (LPN), and Staff D, LPN, separately, rather than together as directed by the Assistant Director of Nursing (ADON). Although Staff B stated she lacked the licensure to conduct counts, she claimed Staff C, LPN, insisted she participate and sign the documentation. […]

• No harm, potential for more than minimal, patternF725Mar 12, 2026

  Based on resident council meetings, Electronic Health Record (EHR)review, document review, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 6 residents reviewed (Resident #27, #53, #11 and #15). The facility reported a census of 45 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #27 had a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. […]