Parkland Manor.

“A resident fell at the dining room table, hit their head, was transported to the hospital and diagnosed with a head contusion. The home failed to report this incident to the Department within 24 hours as required.”

“Blood glucose readings were documented on a resident's medication record without corresponding readings found in the resident's glucometer, indicating improper documentation and monitoring of blood glucose testing ordered four times daily.”

“A resident prescribed insulin on a sliding scale twice daily had insulin administered according to the medication administration record, but there was no corresponding blood glucose reading found in the resident's glucometer, and staff could not confirm the blood glucose check was completed prior to insulin administration.”

“Exit signs were missing over 3 of 4 exit doors in the home's new secured unit. The facility serves 56 residents and is required to have properly marked exit signs at all exits.”

“A completed preadmission screening form was not available for a resident at the time of inspection, although the resident had been admitted to the home.”

“Resident was not changed on schedule as indicated in their Resident Assessment and Support Plan (RASP). The resident has a 2-hour toileting schedule but was not changed from 11:30 a.m. to 4:30 p.m.”

“Initial medical evaluation forms were incomplete. One form was missing page 2 and the medical professional license number. Another form did not indicate whether the resident's needs could be met in a personal care setting.”

“Prescription medications in cups were left unattended and unlocked on top of a medication cart when the administrator stepped away to use the bathroom.”

“A completed written initial assessment on the Department's assessment form was not completed within 15 days of a resident's admission.”

“Multiple Resident Assessment and Support Plans (RASPs) did not document required equipment or assistance levels: one did not indicate 3-person assist needed during morning care and Hoyer lift use; another did not include Hoyer lift or hospital bed with side rails; another did not include Hoyer lift for transfers. Additionally, some residents' assessments were outdated.”

“A chair in the smoking area had a rope material seat and back that is flammable and poses a fire hazard in the smoking area.”

“Resident found lying on floor bleeding from head on 9/30/24 and hospitalized, but incident report was not submitted to the Department until 10/3/24, exceeding the required 24-hour reporting timeframe.”

“Resident #3 does not have a quarterly account of financial transactions in the record for 2024.”

“Resident #2 requires 2 bed enabler bars; one bar was not covered and posed a possible limb or head entrapment hazard, with the opening measuring more than 4 3/4 inches.”

“Feces and urine stains were noted on the toilet seat, sink and trash can lid in the bathroom in Resident Room A-18.”

“Sleeping hours fire drills occurred on 5/21/23 at 6:22 AM and 8/31/24 at 11:45 PM, exceeding the required 6-month interval.”

“Resident #4's Lantus Solostar 100 Unit insulin pen was open in the medication cart with no date indicating when it was opened or when it expires. Per manufacturer instructions, the pen expires 28 days after opening. This is a repeat violation from 10/3/23.”

“The secured dementia unit's exterior keypad directions located at the patio door entrance do not match the number code that is taped to the building's exterior keypad.”

“The administrator did not provide immediate access to a resident's support plan upon request by a DHS representative. The record was not provided until later via email.”

“The home did not complete and send an incident report to the department within 24 hours of a resident having a fall on 7-30-24 that contributed to the resident's death on 7-31-24.”

“Two resident support plans do not include the resident's signature or documentation that the resident was unable to participate in plan development.”

“Resident's support plan (RASP) contained inconsistent resident identification and failed to address documented behavioral and physical assistance needs including transfers, toileting, bladder/bowel management, anxiety, and unreliable self-reporting. The plan incorrectly indicated the resident was independent when staff interviews revealed significant support needs.”

“Resident #1's Resident Assessment and Support Plan (RASP) did not indicate whether the resident was unable to participate, declined to participate, refused to sign, or was unable to sign the RASP.”