Parkview Home

In the surveyor’s words

From the most serious findings on record at Parkview Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Feb 22, 2024

  Based on observation, interview, and document review the facility failed to ensure insulin was administered according to manufacturer's guidelines for 1 of 1 resident (R1) resulting in the potential for serious harm or death when R1 had to be sent to emergency department (ED) for hypoglycemia (low blood sugar (BS)) when staff administered R1's insulin without ensuring he ate within the required time frame of 5-10 minutes. The IJ began on 2/5/24, when licensed practical nurse (LPN)-A failed to follow manufacturer guidelines when administering Novolog (a rapid acting insulin) to R1. R1 was administered insulin at 11:14 a.m. without being fed any type of meal or sustenance within 5-10 minutes of administration and was subsequently sent to the ED with severe hypoglycemia for medical treatment. […]

• Immediate jeopardy, isolatedF580Oct 29, 2021

  Based on interview and document review, the facility failed to identify, intervene and notify the physician for 1 of 1 resident (R22) with a significant medical decline requiring immediate medical assessment. The facility's failure resulted in R22 being sent from the facility via ambulance (EMS) to a local hospital and immediately transfered to a regional hospital for a higher level of care (ICU). R22 succumbed to his illness and later died . The IJ began on [DATE], when R22's decline began to occur and staff failed to identify abnormally low oxygen saturations (SpO2), causing R22 to become hypoxic (lack of oxygen in blood). […]

• No harm, potential for more than minimal, widespreadF865Apr 24, 2025

  Based on interview and document review, the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 18 residents. Findings include: Review of the monthly QAPI meeting minutes from November 2024 identified department heads were bringing data forth to QAPI on various topics such as medication errors, falls, pressure ulcers, weight loss, pharmacy services, infection control, admissions and discharges, staff agency use, adverse event monitoring however, only falls and pressure ulcers had a benchmark goal identified with data but no analysis of the data or identified actions the facility… […]

• No harm, potential for more than minimal, widespreadF867Apr 24, 2025

  Based on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 18 residents. Findings include: Review of QAPI minutes from 11/8/24 through 4/11/25 identified No PIP projects were noted. Interview on 4/22/25 with regional administrator (RA) identified the facility had identified a PIP project however, they had not developed a goal, there was no action plan, it had not been discussed at the QAPI meeting, and no staff had been trained. The RA agreed the facility failed to have the identified PIP follow through. […]

• No harm, potential for more than minimal, widespreadF868Apr 24, 2025

  Based on interview, and document review, the Quality Assurance (QA) committee failed to ensure they received reports from the infection preventionist on the infection control program for 1 of 3 quarters reviewed. Findings include: Review of monthly QAPI meeting minutes of November 2024, January 2025 and April 2025 identified that April had no data brought forth or report on the infection control program for review by the QAPI committee. The April QAPI meeting sign in sheet identified attendance by the director of nursing (DON) as the infection preventions/DON. Interview on 4/22/25 at 4:46 p.m., with the administrator identified he was unaware that the infection preventionist had not provided data or a report on the infection control program however, he confirmed he was at the meeting. […]