Parkside Health And Wellness Center

Based on observation, interview, and record review, the facility failed to ensure a cook followed the standardized recipe for sauce preparation. This failure had the potential to affect food palatability (referred to the pleasantness of taste; may influence behavior, particularly concerning the drive to eat) for 48 residents. Findings: A review of the lunch recipe scheduled on 5/29/25 indicated, for 48 residents: Teriyaki Fish. Sauce: Low sodium soy sauce 1 ½ cups. During a food preparation observation and interview in the kitchen on 5/29/25 at 9:55 A.M., the dietary cook (DC) poured 1 ¼ cups of low sodium soy sauce into a measuring cup. The DC stated that there was 1 ¼ cups of low sodium soy sauce in the measuring cup to make the teriyaki sauce. The DC poured the cup contents into the cooking pan. During an interview with the dietary manager (DM) on 5/29/25 at 1:15 P.M., the DM stated that the DC should follow all recipes approved by the registered dietitian. The DM further stated that the DC should have reviewed the recipe and should have poured 1 ½ cups of low sodium soy sauce to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure two residents (Resident 31 and Resident 10) were treated with dignity and respect when - Resident 30 and Resident 10 were not offered a table to dine in the dining room with other residents. -Residents 30 and 10 ate their meal at a table that was not clean. These failures had the potential to affect residents' psychosocial well-being related to dignity and respect. Findings: A dining observation and interview was conducted with Resident 31 on 5/27/25 at 11:36 A.M. in the dining room. Resident 31 and Resident 10 were both seated on a chair waiting for other residents to vacate a table so that they may eat. Resident 31 stated that he was frustrated to wait for a table to be vacated. During a follow-up observation on 5/27/25 at 11:47 A.M. in the dining room, Resident 31 and Resident 10 stood up and took open seats vacated by other residents who were finished eating. The tablecloth was observed filled with food debris from the previous residents who ate at the table. An interview was conducted with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate services for prevention of a pressure ulcer (PU - injury to the skin and underlying tissue resulting from prolonged pressure) for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to develop a PU. Findings: Resident 1 was admitted to the facility on [DATE] per the facility's Resident Face Sheet, with diagnoses of osteoarthritis (joint disease that causes loss of mobility) and dementia (memory problem). A review of Resident 1's nursing care plan (NCP - detailed nursing care that a resident receives) dated 5/27/24 indicated, Resident 1 will only sit on the wheelchair with foam for maximum of 2 hours. During an initial observation on 5/27/25 at 8:13 A.M., Resident 1 was observed sitting on her wheelchair in her bedroom. Observations were conducted on 5/27/25 at 10:13 A.M. and 1:15 P.M. Resident 1 was observed sitting on her wheelchair in her bedroom. A follow-up observation and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a nasal cannula (a flexible tubing that delivers oxygen via the nose) was labeled with a date, for one of 13 sampled residents (Resident 21). This failure had the potential for oxygen tubing to be used past the recommended date, increasing the potential for bacteria to form inside the nasal cannula and potentially cause respiratory infection to Resident 21. Findings: Resident 21 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure (a disease causing difficulty breathing) and chronic obstructive pulmonary disease (a lung disease), per the facility's admission Record. On 5/27/25 at 11:45 A.M., a nasal cannula attached directly to an oxygen concentrator (a machine that delivers oxygen) was observed at Resident 21's bedside. The nasal cannula was not dated or labeled. A review of Resident 21's medical record was conducted on 5/28/25. A review of the physician's orders indicated Resident 21…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify a decline in left hand flexibility for one of two residents (Resident 34), reviewed for range of motion (ROM). As a result, there was the potential for Resident 34 to have a deterioration in ROM, resulting in a loss of independence for activities of daily living (ADL-dressing, bathing, grooming, and personal hygiene). Findings: Resident 34 was admitted on [DATE], with diagnoses which included rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity), per the facility's admission Record. On 12/6/21 at 8:46 A.M., an observation and interview was conducted with Resident 34, while in her room. Resident 34 was standing with her left hand clutched in a fist. Resident 34 stated her left hand started to ball-up in August after she tripped. Resident 34 was physically unable to fully extend her fingers out, without manually using her right hand to assist with the extension.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure safe and effective Dietetic Services oversight when: 1. A menu alternative was produced without weighing the ingredients, 2. The same food alternative was allowed daily for one resident, and 3. Documentation of ongoing collaboration between the RD and the FNSD was not maintained. This failure to ensure effective oversight of the day-to-day dietetic services operations had the potential to place 50 residents at nutritional risk, and further compromise the residents' medical status. (Cross reference F803) Findings: 1. On 12/8/21 at 11:31 A.M., an observation of the lunch food production was conducted. The main entrée was a three-ounce portion of tilapia. Dietary Aide 1 (DA 1) was preparing a grilled cheese sandwich. Per DA 1, the grilled cheese sandwich was for Resident 23. DA 1 stated the facility offered an alternate menu of three or four items in the event a resident did not want the main entrée. DA 1 stated she used two slices, or two ounces of cheese, to make the sandwich. On 12/8/21 at 11:36 A.M.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the nutritional adequacy of an alternate menu item offered to residents. This failure had the potential to result in further compromised medical and nutritional status of residents. Findings: On 12/8/21 at 11:31 A.M., an observation of the lunch food production was observed. The main entrée was a three-ounce portion of tilapia. Dietary Aide 1 (DA 1) was preparing a grilled cheese sandwich. Per DA 1, the grilled cheese sandwich was for Resident 23, who requested the sandwich every day for lunch. DA 1 stated the facility offered an alternate menu of three or four items in the event a resident did not want the main entrée. DA 1 stated she used two slices, or two ounces of cheese, to make the sandwich. On 12/8/21 at 11:36 A.M., a concurrent interview and observation of DA 1 was conducted. DA 1 stated a portion size of the cheese was two slices to make one sandwich. DA 1 placed two slices of cheese on a food scale and read the weight under one ounce. DA 1 took two different slices of cheese from the box,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure practices that mitigated the risk of resident food contamination were followed, when: 1. Dishware and utensils were stored while wet. In addition, wet water pitchers were air dried outside of the kitchen next to soiled linen barrels. 2. Resident dishware and kitchen equipment were stored with dirt, debris, and objects resembling rat feces on them. 3. Spoiled produce was stored amongst unspoiled produce. 4. Clean dishware and utensils had food debris on them. 5. Glassware had cracks and a food scoop had a melted handle. These failures to mitigate potential food contamination may result in foodborne illness (illness caused from consumption of contaminated or toxic food). Findings: 1. On 2/4/20 at 8:15 A.M., a joint kitchen observation and interview was conducted with the DDS. Five plastic water pitchers and two plastic food prep tubs were wet when stored in the cabinet. Two wet food scoops were stored in the drawer above the cabinet. The DDS stated clean dishes and utensils should not have been put away…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility's policy and conduct a bioethics committee (committee to support resident rights and make decisions regarding healthcare) when making complex decisions on behalf of one of 15 residents (9) who lacked decision making capacity and had no responsible party. This failure placed Resident 9 at risk for having medical decisions made that were not in the resident's best interest. Findings: Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include schizophrenia (a disease characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities), per the facility's admission Record. On 2/4/20 at 10:19 A.M., an observation was conducted. Resident 9 was propelling himself up and down the hall in his wheelchair. Resident 9 made mumbling noises and laughed when spoken to. Resident 9 would not engage in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect resident belongings for one of 15 residents (27) reviewed for personal property. This failure resulted in a potential for resident to resident altercation between Resident 27 and Resident 35. Findings: Resident 27 was admitted to the facility on [DATE], with diagnoses which included, anxiety disorder (a long standing mental disorder with persistent worry and fear that interfere with daily activities) and schizophrenia (a mental disorder of thinking and behavior that impairs daily functioning), per the facility's admission Record. On 2/4/20, at 3:35 P.M., an interview and observation with Resident 27 was conducted. Resident 27 was sitting on his bed and stated his roommate, Resident 35, was stealing his clothes. Resident 27 stated the SSD was informed a week ago about the incident and told Resident 27 that his closet would have to be locked. Resident 27 stated, nothing had been done and felt frustrated because there were no locking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure wound treatments were consistently provided as ordered to one of 15 residents (31), reviewed for quality of care. In addition, a physician's wound treatment order was not carried out, or clarified by nursing staff. These failures had the potential to negatively impact Resident 31's wound healing and to impede the coordination of care. Findings: Resident 31 was admitted to the facility on [DATE] with diagnoses to include diabetes mellitus (inability to control blood sugar) with foot ulcer (open wound) and atherosclerosis (narrowing via the build-up of fats/plaques) of native arteries of left leg with ulceration of other part of foot, per the facility's admission Record. 1a. On 2/4/20 at 9:40 A.M., an observation and interview was conducted with Resident 31. Resident 31 was sitting in bed and his right foot was wrapped in a pressure-offloading boot. Resident 31 stated he had wounds on his feet. Resident 31 stated his bandages were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer tube feedings (places food and fluids directly into the stomach through a tube inserted in the abdomen) consistent with a physician's order for one of two residents (26) reviewed for tube feeding. This failure had the potential for Resident 26 to be placed at risk for altered nutrition related to inadequate caloric intake. Findings: Resident 26 was admitted on [DATE] with diagnoses which include dysphagia (difficulty swallowing) and adult failure to thrive (loss of appetite) per the facility's admission Record, dated 2/7/20. A record review of Resident 26's Order Summary Report, dated 1/31/20, indicated Resident 26 had a physician's order, dated 1/1/20, to receive 1120 milliliters (mls) of tube feeding, starting at 6 P.M. to run 14 hours daily. A record review of Resident 26's Medication Administration Records (MARs), dated 1/1/20-1/31/20, and 2/1/20-2/29/20, indicated LNs documented the completed amounts of tube feeding for Resident 26 as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.