Parkview Julian Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF656Mar 13, 2025

  Based on interview and record review, the facility failed to follow one of three sampled residents (Resident 1) care plan (personalized plan of care outlining a person's needs and how they will be addressed) to ensure Resident 1 who was high risk for falls (to move downward, typically rapidly and freely without control, from a higher to a lower level), had history of falls, and had Alzheimer's disease (progressive and fatal brain disorder that causes memory loss, cognitive decline [gradual decrease in mental abilities, such as memory, attention, reasoning, and judgment], and behavioral changes), had a floor mat (cushioned floor covering designed to reduce the impact of a fall, minimizing the risk of injury) to the right side of the bed and was wearing nonskid (designed to prevent sliding… […]

• Actual harm, isolatedF699Apr 6, 2023

  Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P), titled Trauma [event that causes long-lasting mental or emotional damage] Informed Care: Screening [assess for risk factors], Training, and Care Integration Program, when: 1. Medical Records (MR) staff and Dietary Aide (DA) 3 did not respond to one of one resident's (Resident 22) request to identify themselves. This failure resulted in Resident 22 weeping and expressing fear when his trauma response was triggered by staff. 2. Social services did not screen newly admitted residents for a history of trauma for five of six sampled residents (Resident 417, Resident 115, Resident 10, Resident 38, and Resident 39). 2. […]

• Actual harm, isolatedF656Feb 2, 2023

  Based on interview and record review, the facility failed to develop and implement a care plan for one of three sampled residents (Resident 1) with a known history of wandering, which resulted in Resident 1 wandering outside of the building and sustaining a fall. This required the resident to be transported to the hospital where the resident was diagnosed and treated for a fracture ( break in bone) of C1 and C2 (cervical vertebrae -bone at the top of the spine [neck] at the base of the skull) and nasal (bone in nose) tip fracture. […]

• Actual harm, isolatedF692Dec 16, 2021

  Based on observation, interview, and record review, the facility failed to ensure nutritional needs were met for one of eight resident's (Resident 1) on enteral feedings (nutrition provided through a tube into the stomach). This failure resulted in Resident 1's developing elevated blood sugar levels (blood sugar over 180) and a weight gain of 22 pounds in six and one-half months. Findings: During an observation on 8/10/21, at 1:52 PM, in Resident 1's room, Resident 1 received a continuous enteral feeding of [MEDICATION(S)] 1.5 by a pump. […]

• No harm, potential for more than minimal, widespreadF578Nov 21, 2024

  Based on interview and record review, the facility failed to ensure: 1. Six of 20 sampled residents (Resident 58, Resident 87, Resident 193, Resident 22, Resident 17, Resident 70) had a signed and dated Advance Directive (AD - a legal document that provides instructions for medical care and only go into effect if the individual is unable to make decisions for themselves) 2. Document five of 20 sampled residents (Resident 344, Resident 4, Resident 68, Resident 60, and Resident 45) were informed about their right to complete and Advance Directive or had evidence of declining to complete an Advance Directive. […]