Signature Healthcare at Parkwood

In the surveyor’s words

From the most serious findings on record at Signature Healthcare at Parkwood, in the surveyor’s own words.

• Immediate jeopardy, patternF690Nov 10, 2022

  Based on observation, record review, and interview, facility failed to ensure thorough assessments of residents with urinary catheters to identify change in conditions, failed to prevent urinary tract infections for residents with and without urinary catheters, and failed to notify physicians of residents with change of conditions to implement timely treatment for 4 of 5 residents reviewed for urinary tract infections and urinary catheters resulting in immediate jeopardy when residents were hospitalized with sepsis and renal failure (Residents E, F, G, and H). The immediate jeopardy began on [DATE] when Resident E had an indwelling urinary foley catheter changed with blood tinged urine in tubing without physician notification. […]

• Actual harm, patternF867Nov 10, 2022

  Based on observations, interviews and record reviews, the facility failed to identify Urinary Tract Infections (UITs) as a high-risk concern area through their Quality Assurance Program (QAPI) which resulted in actual harm when 4 of 5 residents reviewed for UTIs resulted in immediate jeopardy after acute changes of condition, wherein; Resident B ultimately died of septic shock, Resident G was admitted to the hospital and diagnosed with sepsis secondary to a UTI, Resident F's acute change of condition was not noticed by facility staff so that her family member called 911 and she was also diagnosed with a UTI, and Resident H was not treated promptly to prevent pain and burning when voiding after they began to exhibit signs and symptoms of a UTI. […]

• Actual harm, isolatedF689Feb 6, 2024

  Based on observation, interview and record review, the facility failed to ensure a cognitively impaired and dependent resident was safe from an injury of unknown origin (Resident F), failed to ensure a resident did not have vaping materials in the room (Resident 72) and failed to prevent recurring falls for a resident who was identified as a high risk to experience falls (Resident H) for 3 of 3 residents reviewed for accidents. The deficient practice resulted in Resident F sustaining a left arm fracture. Findings include: 1. During an observation, on 2/1/24 at 12:01 p.m., Resident F was sitting up in a wheelchair in the dining room, a Hoyer pad was under the resident and there was a splint on the left upper arm. […]

• Actual harm, isolatedF684Nov 10, 2022

  A. Based on observations, interview, and record reviews, the facility failed to recognize an acute change of condition in order to provide appropriate and timely nursing services for a resident, (Resident F) which resulted in actual harm when she was ultimately hospitalized and diagnosed with sepsis secondary to a UTI, acute kidney injury classified as pre-renal failure due to dehydration and low potassium and magnesium levels for 1 of 5 residents reviewed for urinary tract infections and urinary catheters. […]

• Actual harm, isolatedF689Nov 10, 2022

  Based on observation, interview, and record review, the facility failed to ensure a resident's environment was free from the potential for accidents which resulted in actual harm when she tripped over an uneven surface of the floor and sustained multiple fractures for 1 of 3 residents reviewed for falls (Resident G). Findings include: On 11/1/22 at 10:24 a.m., Resident G was initially observed. She was seated upright in a broad wheelchair at the nurses' station and activity lounge. She as neat, clean, and pleasantly confused as she smiled at other passing residents and staff. Both her feet were in protective foam pressure reliving boots. She was unable to answer simple questions but smiled and nodded in response to conversation. […]