Parkwood Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Parkwood Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 3, 2024

  Based on interview, record review, review of facility policy, and review of a facility investigation, the facility failed to have an effective system in place to ensure resident safety for one (Resident (R) 140) of two sampled residents reviewed for elopements. On 09/04/2022, R140 eloped from the facility unescorted and unsupervised, and required police intervention to locate the resident and return him to the facility. On 06/28/2024, the Administrator and Director of Nursing (DON) were provided a copy of the CMS IJ Template and notified that the failure to ensure residents were provided supervision and protected from further elopement, constituted immediate jeopardy at F 689. The Immediate Jeopardy (IJ) at F 689 also constituted Substandard Quality of Care at 42 CFR 483.25. […]

• No harm, potential for more than minimal, widespreadF755Jan 8, 2026

  Based on observation, interview, record review and facility policy review, the facility failed to ensure drug records were in order and an account of all drugs was maintained and periodically reconciled for 4 out of 12 residents who received narcotic medications, out of the total sample of 23 residents. The findings include: Review of the facility policy titled, [NAME] Healthcare Medication Administration Policy, dated 01/05/2025, revealed the facility was to follow the five rights of medication administration. Per review the five rights included the: right resident, right medication, right dose, right route, right time and must be confirmed at the following stages during medication administration. […]

• No harm, potential for more than minimal, widespreadF761Jan 8, 2026

  Based on observation, interview, and facility policy review, the facility failed to ensure all medications and wound care products used in the facility were stored and labeled in accordance with professional standards, with the potential to affect 25 out of 25 residents receiving wound care. The findings include: Review of the facility's policy titled, Medication Storage, undated, revealed drugs and biologics were to be stored in the packaging, containers or other dispensing systems in which they were received. Per policy review, only the issuing pharmacy was authorized to transfer medications between containers. Continued review revealed the nursing staff were responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. […]

• No harm, potential for more than minimal, widespreadF812Jul 3, 2024

  Based on observation, interview, record review, and review of facility policy and food storage reference material, the facility failed to store food in accordance with facility policy and accepted standards of food service/management. Foods were not dated and/or labeled when opened. The deficient practice had the potential to affect 85 of 89 residents who consumed food stored and /or used in this kitchen. The findings include: A review of the facility policy titled Food Storage, dated 03/25/2012, revealed food is stored and prepared in a clean safe sanitary manner that will comply with state and federal guidelines. Per the policy, containers for bulk items are leakproof, non-absorbent, and sanitary, with tight-fitting lids. […]

• No harm, potential for more than minimal, patternF657Jan 8, 2026

  Based on interview, record review and review of facility policy and procedure, the facility failed to ensure resident participation in the development of the comprehensive care plan for 3 of 8 residents (Resident (R)16, R94, and R72) out of the total sample of 23 residents. The findings include:Review of the facility policy titled, Care Planning - Comprehensive Person -Centered, undated revealed, To the extent practicable, the resident/resident representative will be provided with opportunities to participate in the care planning process. Per policy review All reasonable efforts were to be made for the resident/resident representative to be informed in the language he/she could understand regarding his/her total health status, including but not limited to, his or her medical condition. […]