Park Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, family and staff interview, the facility to failed to ensure they held, managed, safeguarded and accounted for resident's personal funds entrusted in the care of facility staff for 2 of 4 residents sampled (Residents #1 and #4). The facility reported a census of 35. Findings include:1. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 Brief Interview for Mental Status (BIMS) assessment resulted in a score of 5 out of 15, which indicated severely impaired cognition. The MDS list of diagnoses included Non-Alzheimer's dementia. The MDS indicated Resident #1 admitted to the facility on [DATE]. Review of the Care Plan, dated 6/6/25, revealed a plan to address Cognitive Loss. During an interview on 11/24/25 at 10:45 AM, the Administrator reported Staff A, former Social Services Specialist worked at the facility from June 24, 2024 to October 17, 2025. The Administrator explained that within the scope of her position, Staff A made deposits 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, review of Resident Council Meeting minutes, review of Call Light Logs, clinical record review, resident, resident family member, and staff interviews, the facility failed to ensure staff responded to call lights within in 15 minutes for 5 of 5 residents reviewed for call lights (Residents #3, #15, #38, #14 and #18). The facility reported a census of 38 residents. Findings include: Review of April 2025 Resident Council Meeting minutes, dated 4/23/25, revealed the following comments: One resident mentioned that it seems as though the call light response times have improved, except on weekends. Another resident disagreed with the wait time improvement and remarked that she still has to wait for extended periods for her call light to be answered. 1. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored 12 out of 15 on a BIMS exam, which indicated a moderately impaired cognition. The MDS list of diagnoses included heart failure, stroke, and urine retention.…

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 clinical record review, receiving facility staff interview, and discharging staff interviews the facility failed to provide an accurate representation of a resident's behaviors and to ensure discharge needs are identified within the discharge planning process for one of one residents (Resident #1) reviewed. The facility reported census was 36. Findings include: The Minimum Data Set (MDS) dated [DATE], included an incomplete Brief Interview for Mental Status (BIMS). The BIMS is used to determine cognitive status. Section C, for Cognitive Patterns indicated Resident #1 had short term and long term memory problems, and moderate impaired cognitive skills for daily decision making. Section E, for Behavior indicated Resident #1 wandered daily; and wandering significantly intruded on the privacy or activities of others. Section E indicated Resident #1 did not display hallucinations or delusions. The MDS documented Resident #1 independent with transfers and ambulation. The MDS list of diagnoses included:…

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 clinical record review, staff interview, and facility policy review the facility failed to ensure timely follow-up completed in response to Medication Regimen Review recommendations for 1 of 5 residents reviewed for unnecessary medications (Resident #24). The facility reported a census of 34 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 5/15/24 revealed the resident was rarely to never understood, and took hypnotic medication. The Care Plan dated 10/1/23 titled LTC Psychotropic Medication Use revealed the following intervention: Monitor for adverse reactions r/t (related to) temazepam, quetipine, trazodone. The Physician Order First Dose Date/Time dated 12/4/2023 at 9:00 PM revealed an order for Temazepam 7.5 mg (milligram) oral cap at HS (night). Review of the Phone Message/Call Note dated 3/31/24 at 3:59 PM revealed, in part, the following: In December, the dose of temazepam was successfully decreased to 7.5 mg daily at bedtime. There have been some behaviors during the day time with agitation and crying and it…

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 the clinical record review, interviews, and the facility policy, the facility failed to implement interventions prior to the administration of an antianxiety medication, and failed to attempt a gradual dose reduction for a resident on an antidepressant for 2 of 5 residents reviewed for unnecessary medications (Resident #19 and Resident #21). The facility reported a census 34 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was rarely or never understood. The MDS revealed the resident wandered 4 to 6 days out of the last 14 day look back period. The MDS revealed the resident took antipsychotics, antianxiety, and antidepressants. The Care Plan, initiated on 6/10/24, for LTC Behavioral Symptoms IPOC (Interdisplinary Plan of Care) included Interventions to: provide care with smile, gentle touch, voice, reassurance; evaluate for signs of pain during care and intervene prior to giving care; evaluate usual time, duration, and frequency of behavior, evaluate…

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 clinical record review, policy review and staff interviews, the facility failed to provide transfers using mechanical lifts in a dignified, and respectful manner for 2 of 3 residents reviewed (Resident #1 and Resident #4). The facility reported a census of 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 2/14/24, revealed Resident #1 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, indicating intact cognition. The MDS revealed the resident required substantial/maximal assistance with lying to sitting on the side of the bed and chair/bed to chair transfers. The MDS revealed the resident required partial/moderate assistance with rolling from left to right and sitting to lying. The MDS revealed medical diagnoses of generalized muscle weakness and cerebral vascular accident (CVA), transient ischemic attack (TIA), or stroke. The Care Plan revealed a focus area for Activity of Daily Living (ADL) mobility dated 9/22/23. The interventions (no date provided) included providing assistance to support level of need; encouraging,…

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 clinical record review, policy review and interview, the facility failed to report a staff to resident alleged assault within the required 24 hour time frame for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 34 residents. Findings include: A review of a Facility Reported Incident revealed a submission date of 4/12/24 at 4:02 PM for an allegation of abuse that occurred on 4/9/24 at approximately 1:00 PM. The incident summary revealed Staff A, CNA (Certified Nurse Aide) came to the DON (Director of Nursing) on 4/9/24 and stated that during a transfer she observed Staff C, CNA grab the resident by the waist band and pull him up from the wheelchair. She stated once the paddles [two paddles that when lowered form a seat] on the lift were in place, Staff C let go of the resident and then he flopped down onto the paddles [seat]. When transferring Resident #1 to bed, Staff C told the resident to stand up. Resident #1 stated he was trying and to give him a minute. Staff C then leaned forward and grabbed the resident by the pockets of his pants to stand…

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 clinical record review, policy review, and staff interviews the facility failed to thoroughly investigate a staff to resident alleged abuse for 1 of 3 residents reviewed for abuse (Resident #1). The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 2/14/24, revealed Resident #1 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The MDS revealed the resident required substantial/maximal assistance with lying to sitting on the side of the bed and chair/bed to chair transfers. The MDS revealed the resident required partial/moderate assistance with rolling from left to right and sitting to lying. The MDS revealed medical diagnoses of generalized muscle weakness and cerebral vascular accident (CVA), transient ischemic attack (TIA), or stroke. The Care Plan revealed a focus area for Activity of Daily Living (ADL) mobility dated 9/22/23. The interventions (no date provided) included providing assistance to support level of need; encouraged, cued, and prompted 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 interview, record review, facility job description review, the facility failed to ensure the Administrator was appropriately licensed to act as the Administrator for the facility. The facility reported a census of 31. During the entrance conference on 7/24/23 at 11:12 AM, the DON (Director of Nursing) stated the Administrator was currently at the other facility she managed and wouldn't make it to this facility today. During an interview on 7/26/23 at 9:25 AM, the Administrator queried to supply a copy of her license and she stated she didn't have a license, she had a provisional license for the other facility (not facility surveyed at present time). She stated she was in the process of getting a waiver. The Administrator asked if when she took the Administrator position she would be managing both facilities and she stated yes. She stated the provisional license couldn't be used for both facilities and the provisional license was issued for the other facility. She stated she applied for the waiver and if all else failed someone at this facility needed to get a provisional…

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 develop a focus care area for diabetes on the care plan for 1 of 12 residents reviewed for care planning development (Resident #10). The facility reported a census of 31. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognition impairment. The MDS revealed a diagnosis of diabetes mellitus (DM). The MDS documented the resident received insulin injections 7 out of 7 days. The Care Plan with initiated date of 4/4/23 lacked documentation of a focused care area and interventions for the diagnosis of DM. The Electronic Medical Record revealed a diagnosis of Type II DM without complications dated 4/4/23. The Physician Orders revealed the following orders: a. Lantus 100 units/ml (milliliter) solution insulin vial- Inject 12 units subcutaneously once daily ordered on 4/4/23 b. Metformin 1000 mg (milligram) tablet-…

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 respond timely to address and treat a resident's symptoms of a urinary tract infection (UTI) for 1 of 4 residents reviewed for urinary tract infections (Resident #17). The facility reported a census of 31. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognitively intact. The MDS documented the resident always continent of urine. The MDS revealed the resident a UTI in the last 30 days. The MDS revealed the resident received an antibiotic 5 out of 7 days. The Care Plan revealed a focus care area dated 7/11/23 of a history of UTIs leading to hospitalization if not treated promptly. The interventions dated 7/11/23 revealed the resident and family chose to opt out of the UTI protocol and wanted the provider notified as soon as symptoms were reported. The Progress Note dated 7/4/2023 at 11:07 AM revealed the resident…

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 timely interventions and provide adequate supervision for residents with a history of falls and a resident with a history of wandering behavior for two of four residents reviewed for accidents (Resident #18, Resident #5). The facility reported a census of 31 residents. Findings include: 1A. The Minimum Data Set (MDS) assessment for Resident #18 dated dated 4/26/23 and 7/19/23 revealed Resident #18 had severely impaired cognition. Per the MDS dated [DATE] the resident had wandered one to three days during the look back period, and the MDS dated [DATE] revealed the resident and had wandered four to six days but less than daily. The Care Plan for Resident #18 dated 7/30/20 revised on 4/13/22 revealed, [Resident #18] has impaired cognitive function r/t (related to) dementia. She displays short and long term memory loss, disorientation to time, place and situation, confusion and impaired communication/difficulty finding words and/or…

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 consistently document non-pharmacological interventions attempted prior to the administration of as needed antianxiety medication for one of five residents reviewed for unnecessary medications (Resident #19). The facility reported a census of 31 residents. Findings include: Review of the Annual Minimum Data Set (MDS) assessment for Resident #19 dated 6/21/23 revealed the resident had severely impaired cognition. Per this assessment, Resident #19 had received antianxiety medication for four of the last seven days. The Care Plan dated 10/15/20 revised on 8/4/21 documented, [Resident #19] receives psychotropic medications (Seroquel) r/t (related to) increased aggression secondary to dementia and subarachnoid hemorrhage secondary to fall prior to admission. The Physician Order dated 6/30/23 documented, Lorazepam Tab 0.5MG (Milligram), also known as Ativan, an antianxiety medication, with instruction for 1 tablet by mouth twice daily as needed for anxiety/agitation for 90 days (6/30-9/28/23) for Anxiety disorder,…

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.