Parsons Presbyterian Manor

In the surveyor’s words

From the most serious findings on record at Parsons Presbyterian Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Oct 29, 2024

  The facility reported a census of 29 residents. The sample included three residents reviewed for medications. Based on observation, interview, and record review, the facility failed to prevent the significant medication error of cognitively impaired Resident (R) 1. On 09/12/24 Certified Medication Aide (CMA) R incorrectly administered another resident's (R2's) medications to R1, which included Crestor (anti-hyperlipidemic) 20 milligram (mg) and Coreg (anti-hypertensive) 25 mg, as well as R1's scheduled mirtazapine (anti-depressant) 15 mg. […]

• Actual harm, isolatedF686Dec 20, 2022

  The facility reported a census of 25 residents with 14 selected for review, which included two residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to ensure Resident (R)76 and R4 received timely interventions for pressure ulcer prevention, which resulted in R76's development of an unstageable pressure ulcer (unable to determine depth of the ulcer due to overlying slough (dead tissue usually yellow or white) or eschar (dried dead tissue). […]

• Actual harm, isolatedF697Jun 21, 2021

  The facility reported a census of 28 residents. The sample of 15 residents included one resident reviewed for pain management. Based on observation, interview, and record review the facility failed to provide adequate pain management for the Resident (R) 26, when staff failed to administer scheduled pain medication on four occasions due to the unavailability of the physician ordered medication when staff failed to reorder the medication from the pharmacy. The resident stated she had pain at a level worse than a 10 (out of a scale of 0-10, with 10 being the worst) over the weekend due to the lack of scheduled pain medication. Findings included: - Review of R26's Physician Orders, dated 06/01/21, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF814Sep 12, 2024

  The facility reported a census of 28 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests. Findings included: - On 09/10/24 at 10:13 AM, initial tour with Dietary Staff BB revealed two of four compartments dumpster open with exposed trash and garbage. Additionally, discarded building supplies surrounded the dumpster with grass grown over the edges. Dietary Staff BB confirmed the above findings. She reported the facility staff should dispose of garbage and trash in a closed container to prevent harboring of pests and rodents from nesting around the facility. […]

• No harm, potential for more than minimal, widespreadF851Sep 12, 2024

  The facility reported a census of 28 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 12 dates between 07/01/23 and 09/30/23 and 10 dates between 01/01/24 and 03/31/24. […]