PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
admission policy did not limit the facility’s responsibility for resident’s personal
property, and failed to provide completed personal inventory lists for seven of 20 sampled
residents (Resident #245, #69, #20, #14, #66, #69 and #59). The census was 96.
1. Review of the facility’s undated resident admission agreement, showed the following:
-Personal items and services: Any personal items such as TV; radios, cell phones, books,
gifts, dentures and hearing aids are not the responsibility of the community if stolen,
lost or damaged.
During an interview on 12/11/18 at 10:30 A.M., the administrator said he would take the
language out of the admission agreeement removing the facility’s responsibility for
resident’s personal items. He was not aware the agreement included that language.
2. Review of Resident #245’s medical record, showed:
-admitted to the facility on [DATE];
-admitted to hospice services on 11/17/18:
-[DIAGNOSES REDACTED].
Observation on 12/7/18 at 8:32 A.M., showed the resident asleep in bed and covered with a
purple and white afgan. The resident’s closet contained five pair of pants, four shirts
and two pairs of shoes.
Review of the resident’s medical rcord, showed a blank facility property inventory sheet.
3. Review of Resident #69’s medical record, showed:
-admitted on [DATE];
-[DIAGNOSES REDACTED].
Observation of the resident’s closet on 12/7/18 at 10:15 A.M., showed multiple pants,
shirts and shoes. The items had been labeled with the resident’s name.
Review of the resident’s medical record, showed a blank inventory sheet.
4. Review of Resident #20’s quarterly Minimum Data Set (MDS), a federally mandated
asssessment instrument completed by facility staff, dated 9/9/18, showed the following:
-admitted to the facility on [DATE];
-Moderate cognitive impairment;
-[DIAGNOSES REDACTED].
During an interview on 12/6/18 at 9:32 A.M., the resident said his/her spouse gave him/her
a blanket and it disappeared. He/she said the facility made no offer to replace it.
Review of the resident’s medical record, showed a blank personal belongings inventory
sheet.
Observation of the resident’s room on 12/6/18 at 9:32 A.M., 12/7/18 at 6:50 A.M., 12/10/18
at 10:21A.M. and 12/11/18 at 7:03 A.M., showed pictures, a TV and other personal items.
5. Review of Resident #14’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-No cognitive impairment;
-[DIAGNOSES REDACTED].
During an interview on 12/5/18 at 11:30 A.M., the resident said a staff member broke one
of his/her hand held speakers and the facility refused to replace it.
Review of the medical record, showed a blank personal belongings inventory sheet.
Observation of the resident’s room on 12/5/18 at 11:30 A.M., 12/7/18 at 11:45 A.M. and
12/11/18 at 8:56 A.M., showed a stereo system, computer, clothing and multiple other
personal items.

Based on interview and record review, the facility failed to ensure their abuse and
neglect policy identified when, how and by whom determination of capacity to consent to
sexual contact will be made and where this documentation will be maintained. The census
was 96.
Review of the facility’s Abuse Policy and Procedures, dated (MONTH) (YEAR), showed the
following:
-This facility affirms the right of our residents to be free from abuse, neglect,
misappropriation of resident property, corporal punishment and involuntary seclusion;
-Abuse means any physical or mental injury, or sexual assault inflicted upon a resident
other than by accidental means in a facility. Abuse is the willful infliction of injury,
unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or
mental anguish. This also includes the deprivation by an individual, including a
caretaker, of goods or services that are necessary to attain and/or maintain physical,
mental and psychosocial well-being. This assumes that all instances of abuse of residents,
even those in a coma, cause physical harm or pain or mental anguish;
-The policy failed to identify when, how and by whom determination of capacity to consent

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
had complete, accurate and individualized care plans, to address the nutritional status
and pain control for two of 20 sampled residents (Residents #42 and #14). The census was
96.
1. Review of Resident #42’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 7/7/18, showed the following:
-Severe cognitive impairment;
-Extensive to total dependence on staff for all mobility and personal care;
-[DIAGNOSES REDACTED].
-Care area assessment prompted nutritional status to be care planned.
Review of the care plan, dated 7/7/18 and last reviewed and updated on 10/24/18, showed no
documentation regarding nutritional status.
Review of the resident’s weights from 6/18/18 through 11/18/18, showed a weight loss of
15.57%.
During an interview on 12/11/18 at 10:30 A.M., the Director of Nursing (DON) said the care
plan should have included the resident’s nutritional status and updated as needed.
2. Review of Resident #14’s admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-No cognitive impairment;
-[DIAGNOSES REDACTED].
-Frequent moderate pain.
Review of the care plan, dated 6/22/18, showed no documentation regarding the resident’s
pain.
Review of the POS [REDACTED]
-An order, dated 10/24/18, to apply a [MEDICATION NAME] (narcotic [MEDICATION NAME]) 25
microgram (mcg) patch and change every three days;
-An order, dated 11/16/18, to administer [MEDICATION NAME] (narcotic [MEDICATION NAME]) 30
milligrams (mg) one tablet daily at bedtime;
-An order, dated 11/16/18 to administer [MEDICATION NAME] (narcotic [MEDICATION NAME])
5/325 mg every six hours PRN (as needed) for pain relief.
During an interview on 12/11/18 at 10:30 A.M., the DON said pain should have been
addressed on his/her care plan because that was an ongoing issue from the beginning of
his/her stay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure ordered
antibiotics had a reason and frequency for administration, ensure treatment orders
included the location for the application, ensure there were physician orders
[REDACTED].#66, #42, #59, #69, #20, #61 and #92). The census was 96.
1. Review of Resident #66’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/23/18, showed the following:
-No cognitive impairment;
-[DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
-An order dated 10/17/18, to administer Fluconazole (antibiotic) 100 milligram (mg) for
three days;
-No [DIAGNOSES REDACTED].
Review of the POS [REDACTED]
-An order dated 11/18/18, to administer [MEDICATION NAME] (antibiotic) 500 mg one tablet
by mouth twice a day for seven days. No [DIAGNOSES REDACTED].
-An order dated 11/18/18 to administer [MEDICATION NAME] (antibiotic) one gram (gm) one
time NOW. No [DIAGNOSES REDACTED].
-An order dated 11/18/18, to administer Ceftraxone (antibiotic) 500 mg intramuscularly
(IM, injection in to the muscle) one time NOW. No [DIAGNOSES REDACTED].
-An order dated 11/29/18, to administer [MEDICATION NAME] 500 mg one tablet by mouth twice
a day for seven days. No [DIAGNOSES REDACTED].
Review of the POS [REDACTED]
-An order dated 12/7/18, to administer [MEDICATION NAME] 500 mg by mouth twice a day for
seven days;
-No [DIAGNOSES REDACTED].
2. Review of Resident #42’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive to total assistance required from staff for all mobility and personal care;
-Diagnoses included heart failure and dementia.
Review of the resident’s POS, dated 10/26/18 through 10/31/18, showed the following:
-An order, dated 10/31/18, to administer [MEDICATION NAME] (antibiotic) 100 mg by mouth
twice a day for seven days;
-No [DIAGNOSES REDACTED].
During an interview on 12/11/18 at 10:30 A.M., the Director of Nursing (DON) said that
when an antibiotic is ordered it should include the route of administration, the frequency
of administration, the number of days to be administered and the [DIAGNOSES REDACTED].
3. Review of Resident #59’s significant change MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive assistance of staff required for most activities of daily living (ADL’s);
-Total assistance required for toilet use;
-Incontinent of bowel and bladder;
-At risk for pressure ulcers (injuries to skin and underlying tissue resulting from
prolonged pressure on the skin);
-Diagnoses included heart failure, high blood pressure, [MEDICAL CONDITION] (inability to
speak), stroke, dementia, anxiety and depression.
Review of the resident’s care plan, dated 10/24/18, showed the following:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that one
resident received treatment and care in accordance with professional standards of practice
by failing to document the administration of as needed (PRN) pain medication. The failure
prevented the resident from experiencing effective pain control (Resident #14). The sample
size was 20. The census was 96.
Review of Resident #14’s admission Minimum Data Set (MDS) a federally mandated assessment
instrument completed by facility staff, dated 6/15/18, showed the following:
-admitted to the facility on [DATE];
-No cognitive impairment;
-[DIAGNOSES REDACTED].
-Frequent moderate pain.
Review of the care plan, dated 6/22/18, showed no documentation regarding the resident’s
pain or the ordered PRN pain medications.
Review of the physician’s orders [REDACTED].
-An order, dated 9/7/18 to apply a [MEDICATION NAME] (narcotic [MEDICATION NAME]) patch 25
micrograms (mcg) and change every three days;
-An order, dated 10/11/18, to administer [MEDICATION NAME] (narcotic [MEDICATION NAME])
5/325 milligrams (mg) one tablet by mouth twice a day PRN;
-An order, dated 10/11/18, to administer [MEDICATION NAME] (narcotic [MEDICATION NAME]) ER
(extended release) 30 mg twice a day.
Review of the individual controlled substance record, dated 10/14/18 through 10/31/18,
showed the following administrations of [MEDICATION NAME]:
-10/14/18 at 10:00 A.M., 4:00 P.M. and 11:00 P.M.;
-10/15/18, at 6:00 A.M., 1:00 P.M. and 6:45 P.M.;
-10/16/18, at 6:10 P.M. and 11:00 P.M.;
-10/17/18, two handwritten signed out illegible times;
-10/18/18, at 6:10 P.M.;
-10/19/18, at 6:00 A.M., 4:00 .P.M and 10:00 P.M.;
-10/20/18, at 6:00 A.M. and 6:00 P.M.;
-10/21/18, at 11:00 A.M. and 7:00 P.M.;
-10/22/18, at 4:00 A.M. and 6:00 P.M.;
-10/23/18, at 6:00 A.M. and 5:00 P.M.;
-10/24/18 at 6:00 A.M.;
-10/25/18 at 12;00 P.M. and 5:00 P.M.;
-10/26/18 at 10:00 A.M. and 7:30 P.M.;
-10/27/18 at 6:00 A.M. and 8:00 P.M.;
-10/28/18 at 5:00 A.M. and 4:00 P.M.;
-10/29/18 at 5:00 A.M. and 4:00 P.M.;
-10/30/18 at 5:00 A.M., one illegible hand written time and 6:00 P.M.;
-10/31/18 at 7:00 A.M
Review of the resident’s (MONTH) (YEAR) Medication Administration Record [REDACTED].
Observation of the individual controlled substance record, dated 11/1/18 through 11/30/18,
showed the following administrations of [MEDICATION NAME]:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a timely
response to the registered dietician’s recommendation regarding weight loss of 15.57 %
over a six month period for one of 20 sampled residents (Resident #42). The census was 96.
Review of Resident #42’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 10/8/18, showed the following:
-Severe cognitive impairment;
-Extensive to total dependence on staff for all mobility and personal care;
-[DIAGNOSES REDACTED].
Review of the resident’s weights, showed the following:
-Weighed 190 pounds (lbs) on 6/18/18;
-Weighed 191.4 lbs on 7/18/18;
-Weighed 190.6 lbs on 8/18/18;
-Weighed 181.8 lbs on 9/18/18;
-Weighed 170 lbs on 10/18/18;
-Weighed 160.4 lbs on 11/18/18.
Review of the resident’s care plan, dated 7/7/18, showed no documentation regarding weight
loss.
Review of the physician’s orders [REDACTED].
Review of the dietician’s progress note, dated 10/16/18, showed he/she recommended to
increase the Med Pass to 90 cc’s three times a day.
Review of the nurse’s notes, dated 10/16/18, showed no documentation regarding the
dietician’s recommendation or notification to the physician.
Review of the dietician’s progress note, dated 11/16/18, showed he/she recommended to
increase Med Pass to 90cc’s three times a day.
Review of the nurse’s notes, dated 11/16/18, showed no documentation regarding the
dietician’s recommendation or notification to the physician.
Review of the physician’s orders [REDACTED].
-An order, dated 9/14/18, to administer Med Pass 2.0 (medicated nutrition supplement) 60
cubic centimeters (cc) twice a day;
Observation on 12/6/18 at 1:08 P.M., showed the resident sat at the dining room table. A
Certified Nurse Aide (CNA) fed him/her and he/she consumed approximately 10% of the meal.
Observation on 12/7/18 at 9:05 A.M., showed the resident sat at the dining room table. A

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to ensure residents
who recieved dalysis services had current [MEDICAL TREATMENT] orders and also failed to
ensure the dialyisis services had been addressed on the resident’s individual care plans.
The facility also failed to ensure individual [MEDICAL TREATMENT] contracts had been
secured from out sourced [MEDICAL TREATMENT] care centers. This affected two of three
sampled [MEDICAL TREATMENT] residents (Resident #69 and #44). The census was 96.
1. Review of Resident #69’s physician order [REDACTED].M.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facilty staff, dated 8/24/18, showed:
-Cognitively intact;
-Received [MEDICAL TREATMENT] therapy;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated on 11/23/18, showed:
-Problem: Received [MEDICAL TREATMENT] three days a week;
-Goal: Limit the risk of side effects for [MEDICAL TREATMENT] treatments;
-Approaches: Allow the resident to rest after return from [MEDICAL TREATMENT], follow
renal diet, obtain ordered labs, monitor [MEDICAL TREATMENT] for infection and bleeding.
Review of the POS [REDACTED].
During an interview on 12/6/18 at 1:15 P.M., the resident said he/she had gone to [MEDICAL
TREATMENT] for several years. He/she goes three times a week. The facility takes him/her
to the [MEDICAL TREATMENT] center and brings him/her back to the faciliy after [MEDICAL
TREATMENT] therapy. He/she usually eats breakfast and lunch at the facility and when
he/she gets back, staff will provide him/her a late dinner.
During an interview on 12/11/18 at 10:30 A.M., the Director of Nursing (DON) said all
[MEDICAL TREATMENT] resident’s should have current [MEDICAL TREATMENT] orders. The orders
should include when and where the resident attends [MEDICAL TREATMENT]. The [MEDICAL
TREATMENT] site contact information should be included on the order sheet. The care plan
should match the [MEDICAL TREATMENT] orders and include post and pre [MEDICAL TREATMENT]
therapy care.
During an interview on 12/11/18 at 12:18 P.M., the DON said the care plans of the [MEDICAL
TREATMENT] patients should have the [MEDICAL TREATMENT] contact information, the [MEDICAL
TREATMENT] treatment schedule and post treatment care at the facility. The resident’s care
plan did not have the specific [MEDICAL TREATMENT] information on the care plan and the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure resident monthly
pharmacy drug regimen recommendations (MRRs) were reviewed and notify the physician or
medical director of irregularities, for eight of 20 sampled residents (Residents #59,
#152, #6, #30, #61, #14, #52 and #63). The census was 96.
1. Review of Resident #59’s significant change Minimum Data Set (MDS), a federally

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 29 opportunities for error, two errors
occurred resulting in a 6.89% medication error rate (Residents #37 and #42). The census
was 96.
Review of the facility’s undated Medication Administration Policy, last revised on
12/7/18, showed the following:
-Purpose: To provide general guidelines to ensure safe and effective administration of
medication to accommodate resident’s awake times;
-Medications should be administered to accommodate residents’ awake times and within
facilities medication time guidelines. Time critical medications such as those that
require periods of time: Before, after or with meals, will be given with in 30 minutes
before or after meal times and have specified times on the Medication Administration
Record [REDACTED].
Review of the facility’s Policy and Procedure Using and Insulin Flex Pen (pre-filled
insulin pen), dated 5/19/17, showed the following:
-Step one-preparing the flex-pen:
-Wash hands, check the label to ensure you are using the right type of insulin;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure eight of
26 insulin pens (pre-filled) were labeled and dated correctly. The facility census was 96.
Review of the facility’s insulin storage, expiration and disposal policy, revised on
[DATE], showed:
-Dating: upon accessing vial it is dated with the current date;
-Expiration: Insulin is considered viable for 28 days after opening. This is a guideline
from the pharmacy. The date on the vial or pen should be checked before each use and upon
expiration the insulin should be taken to the nursing office.
Observation on [DATE] at 6:50 A.M., of the Terrace nurse medication cart showed:
-Three [MEDICATION NAME] (short acting) insulin [MEDICATION NAME] opened and in use,
undated;
-One Levimer (long acting) insulin flextouch pen opened, undated and in use;
-One [MEDICATION NAME] (long acting) insulin [MEDICATION NAME] pen open, undated and in
use.
Observation on [DATE] at 7:16 A.M., of the Garden nurse medication cart showed:
-One [MEDICATION NAME][MEDICATION NAME] opened, in use and handwritten expiration date
[DATE] written on the pen;
-One [MEDICATION NAME]vial opened, in use and undated;
-One [MEDICATION NAME] (long acting) insulin pen opened, in use and undated.
During an interview on [DATE] at 1:30 P.M., the Director of Nursing said that she expected
the nurses to date the insulins when removed from the medication room refrigerators with
the date the insulin had been removed and the expiration date. Insulin expires 28 days
after it is opened. The nurses should check the insulin date before administering the
insulin to the resident. If an insulin is found undated, the insulin should be disposed
and a new insulin obtained and dated. Undated insulin could be expired and may affect the
effect of the insulin.

Based on observation and interview, the facility failed to ensure pans and serving
utensils were sanitized by not properly using the three compartment sink. This deficient
practice had the potential to affect all residents who ate at the facility. The census was
96.
1. Observation of the kitchen, showed the following:
-On 12/10/18 at 1:32 P.M., Cook E stood at the three compartment sink and washed a large
metal pan in the first compartment filled with soapy water and labeled ‘wash’. Cook E
dipped the pan in the second compartment filled with dingy water, labeled ‘rinse’, turned
the faucet on in the third compartment, labeled ‘sanitize’, and ran the pan underneath the
running water and rinsed off the soap. The third compartment did not contain water or
sanitizer. A tube ran from a bottle of pink sanitizer under the sink into a dispenser on
the wall. A larger tube, tinted with a light pink residue, came out of the dispenser and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to practice
appropriate hand hygiene during personal care and failed to provide a two step [MEDICATION
NAME] skin test (skin test used to check if a person has been infected with [MEDICAL
CONDITION]). This affected two of 20 sampled residents (Residents #84 and #245). The
census was 96.
Review of the facility’s undated Infection Control and Prevention Policy, showed the
following:
Guidelines:
-Observe standard precautions;
-Wash your hands before and after procedures;
-Wash your hands before and after resident contact;
-Wear gloves when appropriate.
-Handwashing:
-Before, during and after food preparation;
-Before eating;
-Before and after resident contact;
-After handling garbage;
-Whenever visibly soiled;
– After blowing nose, coughing, sneezing or using the toilet.
-Glove Usage:
-Gloves should be used in addition to not as a substitute for hand hygiene;
-Contamination is still possible;
-Wear gloves when contact with blood or other potential infectious materials are
possible;
-Do not wear the same pair of gloves for more than one resident;
-Do not wash gloves;
-Remove gloves after caring for a resident;
-Wash hands after removing gloves.