Parkside Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Parkside Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 31, 2025

  Based on medical record review, observation, staff interview, review of the facility policy, and review of online guidelines per the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement treatment once the pressure ulcers were identified. This resulted in Actual Harm for Resident #34, who was admitted to the facility without pressure ulcers and developed pressure ulcers to her right antecubital and left antecubital space (inside of the elbows), which were not identified and treated until they had developed into stage IV ulcers with exposed tendon. This affected one (Resident #34) of five residents reviewed for pressure ulcers. The facility census was 67 residents. […]

• Actual harm, isolatedF686Aug 1, 2023

  Based on record review, observation, staff interview, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin and failed to timely identify a resident's pressure ulcer until it reached an advanced stage which resulted in actual harm to Resident #44 who developed an unstageable pressure ulcer to the left flank which required sharp debridement. The facility also failed to develop and implement a care plan to prevent skin breakdown which placed the resident (#74) at risk for more than potential harm that was not actual harm. This affected two (Residents #44 and #74) of three residents reviewed for pressure ulcers. The facility census was 73. Findings include: 1. […]

• Actual harm, isolatedF700Apr 3, 2023

  Based on medical record review, observation, staff interview, review of hospital records, review of the Food and Drug Administration's guidelines, review of manufacturer's guidelines, and review of facility policy, the facility failed to ensure residents were assessed for appropriateness of bed rail use prior to the installation of bed rails. The facility also failed to assess bed rails for possible areas of entrapment. This resulted in actual harm for one (#14) of three residents reviewed for bed rails when the facility installed grab bars to the resident's bed without conducting an assessment for their use and failed to assess the rails for entrapment risk. The resident subsequently had a fall from bed in which his head became stuck between the mattress and the grab bar. […]

• No harm, potential for more than minimal, widespreadF812Jul 31, 2025

  Based on observation, staff interview, and review of the facility policy, the facility failed to store, prepare, and serve food in a sanitary manner and the facility failed to properly store potentially hazardous cleaning agents away from food preparation areas. This had the potential to affect all residents who receive food from the kitchen. The facility identified ten (Residents #1, #5, #15, #16, #35, #38, #46, #53, #64, #84) who do not receive food from the kitchen. The facility census was 67 residents. Findings include: 1.Observation during the initial tour of the kitchen on 07/21/25 at 8:50 A.M. […]

• No harm, potential for more than minimal, widespreadF880Jul 31, 2025

  Based on record review, review of the facility's Legionella Water Management Plan, observation of hot water tank temperatures, staff interview, and review of the facility legionella mission statement, the facility failed to ensure implementation and maintenance of the legionella water management plan. This had the potential to affect all residents in the facility. The facility census was 67 residents.Findings include: Review of a facility document titled Legionella Water Management Plan undated revealed water entered the facility from the local public water supply and was stored in five holding tanks that were heated by natural gas and/or electricity. There was a tank in a storage room located adjacent to the kitchen that supplied hot water only to the kitchen. […]