Park Rest Hardin County Health Center

Based on policy review, facility working schedule review, calculated time by calendar day list review, Employee Timesheet review, and interview, the facility failed to ensure there was Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, for 37 days ranging from January 2025 through June 2025. The census was 35. The findings include: 1. Review of the facility undated policy titled, Nursing Staff-Staffing Policy, revealed .The facility will assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the resident's needs safely and in a manner that promotes each resident's rights, physical, mental and psychological well-being .The facility will provide at a minimum .55 hours of licensed nursing staff per resident day . 2. Review of the facility Nurses Working Schedule for January 2025, February 205, March 2025, April 2025, May 2025, and June 2025, revealed there was no RN scheduled for 1/4, 1/5, 1/11, 1/12, 1/18,1/19, 1/26, 2/1, 2/2, 2/8, 2/9, 2/15, 2/16, 2/22, 2/23, 3/1, 3/2, 3/8, 3/9, 3/15,…

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 policy review, facility investigation review, medical record review, and interview, the facility failed to report an allegation of abuse and failed to report to local law enforcement, Adult Protective Services (APS), and the Long-Term Care Ombudsman, within 24 hours for the allegations of suspected abuse for 5 of 5 (Resident #11, #12, #17, #19, and #25) sampled residents reviewed for abuse and resident rights. The findings include: 1. Review of the facility undated policy titled, Resident Rights, revealed The resident has the right to a dignified existence, self-determination .The resident has the right to be treated with respect and dignity . Review of the facility undated policy titled, ABUSE, NEGLECT, AND EXPLOITATION, revealed Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Residents must not be subject to abuse by anyone, including but not limited to .facility staff, other residents, consultants, contractors, volunteers, or staff…

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 facility policy review, medical record review, and interviews, the facility failed to follow a physician's order related to contact isolation precautions for 1 of 2 residents sampled (Resident #12) reviewed for infection control. The findings include: 1. Review of the facility policy titled, Infection Control and Prevention Policy, dated 2017, revealed It is the policy of this facility to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection by providing a safe and sanitary environment .A resident with an infection .shall be placed in isolation precautions . 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnosis including Alzheimer, Cerebrovascular Disease, Hemiplegia, and Polyneuropathy. Review of a Microbiology report dated 6/8/2025, revealed Resident #12 had a urine culture that grew out Extended-Spectrum Beta-Lactamases (ESBL) (bacteria is…

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 policy review, facility working schedule, calculated time by calendar day list, and the facility detailed hours report, the facility failed to ensure there was Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, for 29 days ranging from April 1, 2023, through 10/20/2023. The facility's census was 39. The findings include: 1. Review of the facility's undated policy titled, The facility will assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the resident's needs safely and in a manner that promotes each resident's rights, physical, mental and psychological well-being .The facility will provide at a minimum .55 hours of licensed nursing staff per resident day . 2. Review of the facility's Nurses Working Schedule for April 2023, revealed there was no RN scheduled to work 8 consecutive hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/22/2023, 4/23/2023, 4/29/2023 and 4/30/2023. Review of the facility's Calculated Time by Calendar Day, report for April…

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 policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 4 of 10 staff members (Certified Nursing Assistant (CNA) #1, CNA #2, Licensed Practical Nurse (LPN) #1, and Assistant Director of Nursing (ADON) observed during dining failed to use courtesy titles to address residents, failed to provide privacy while assisting with dining, and stood over residents while assisting with dining. The findings include: 1. Review of the facility's undated policy titled, Residents Dignity revealed, .Dignity .means .our interactions .should maintain/enhance his/her self-esteem and self-worth .ensure dignity is provided by .pulling privacy curtain and closing door .respect residents space .knock on door .request permission to enter room .address the resident with the name of their choice . 2. Observation in Resident #35's room during dining on 10/23/2023 at 11:49 AM, revealed CNA #1 entered the room with Resident 35's meal tray and failed to knock on door or acknowledge self before entering. Observation in Resident #35's room…

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 policy review, medical record review, observation, and interview, the facility failed to date and label Percutaneous Endoscopic Gastrostomy (PEG) tube (plastic tube inserted into the stomach to administer liquid food/supplement) feedings for 1 of 2 (Resident #16) sampled residents reviewed for enteral feeding. The findings include: 1. Review of the facility's undated policy titled, Gastrostomy/Nasogastric Tube Feeding, revealed .Provide nourishment to the resident who is unable to obtain nourishment orally. 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses of Dementia, Gastro-Esophageal Reflux Disease, Aphasia, Gastrostomy, and Dysphagia. Review of the admission Minimum Data Set assessment dated [DATE], revealed Resident #16 was assessed as being severely cognitively impaired and receiving nutrition through a feeding tube (peg). Review of a Physician's Order dated 10/21/2023 revealed, .Nutren 1.5 per peg tube at 66 ml (milliliters)/hr (hour) 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.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored when 1 of 3 Licensed Practical Nurse (LPN) left unsecured and unattended medication on top of a medication cart. The findings include: 1. Review of the facility's undated policy titled, Medication Cart, revealed .all containers will be labeled and dated .medication will be kept locked . Review of the facility's undated policy titled, Medication Storage Room, revealed .Medication .will be kept locked when not in use . 2. Observation outside Resident #23's room on 10/24/2023 at 7:34 AM, revealed an orange liquid in a clear medication cup on top of Medication Cart #2. 3. During an interview on 10/24/2023 at 7:35 AM, LPN #4 confirmed that she left the oral medication on top of the medication cart outside Resident #23's room. LPN #1 was asked should medication be left open, unsecured, and out of sight of the nurse during medication administration, LPN #4 stated, No. During an interview on 10/25/2023 at 6:25 PM, the Assistant Director of Nursing (ADON) was asked…

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 policy review, medical record review, observation, and interview, the facility failed to follow Physician's Orders for siderails for 1 of 2 sampled residents (Resident #9) reviewed for physical restraints/siderails. The findings include: Review of the facility's undated policy titled, .Resident Rights, revealed .The resident has a right .to be free from any physical .restraints . Review of the facility's undated policy titled, .Restraints, revealed .if a restraint is needed it will be the least restrictive possible . Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease, Depression, Diabetes, and Hypertension. Review of the Physician's Orders dated 8/5/2021, revealed .Side Rails ½ [one-half] x [times] 2 to assist with repositioning and safety . Review of the Care Plan dated 9/22/2021, revealed, .SIDE RAILS .½ rails up x 2 to assist with repositioning as per Dr.s [Doctor's] order . Observation in the resident's room on…

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 policy review, medical record review, observation, and interview, the facility failed to ensure residents were free from significant medication errors when 1 of 3 nurses (Licensed Practical Nurse (LPN) #1) failed to administer the ordered dose of Sliding Scale Insulin for 1 of 9 sampled residents (Resident #18) observed during medication administration. The findings include: Review of the facility's undated policy titled, .ADMINISTRATION OF DRUGS . revealed .Medications must be administered in accordance with the written orders of the attending physician . Review of the facility's undated policy titled, .SLIDING SCALE INSULIN . revealed .PURPOSE: To ensure insulin is administered .Use resident specific sliding scale as ordered by MD [Medical Doctor] . Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of Diabetes, Adjustment Disorder with Anxiety, Depression, Interstitial Pulmonary Disease, Heart Failure, and Chronic Kidney Disease. Review of the…

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 medical record review, observation, and interview, the facility failed to ensure documentation of medications when 2 of 3 nurses (Licensed Practical Nurse (LPN) #1 and LPN #2) failed to document medications administered on the Medication Administration Record (MAR) for 2 of 9 residents (Resident #28 and #29) observed during medication administration. The findings include: Review of the facility's undated policy titled, .Administration of Drugs, revealed .The nurse administering the medication must record such information on the resident's MAR before administering the next resident's medication .The nurse administering the medications must initial the resident's MAR on the appropriate line and date for that specific day . Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Dementia, Heart Disease, Hypertension, and Acquired Absence of Part of Lung. Review of the Physician's Order dated 7/13/2021, revealed…

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.