Parkside Suites/parkside at North East.

“Six to eight cameras were installed in the main halls of the secured dementia care unit on the first floor, but no signage was posted to indicate video surveillance was in progress, violating resident privacy notification requirements.”

“Direct care staff person A, who was hired, did not receive training in Medication Self-Administration during training year 2024. This is a repeat violation.”

“Direct care staff person A did not receive training in Resident Rights during training year 2024. Staff person B did not receive training in Falls and Accident Prevention during training year 2024. Staff persons A and B did not receive training in Fire Safety by a fire safety expert or by a staff person trained by a fire safety expert during training year 2024. This is a repeat violation.”

“The most recent fire drill conducted during sleeping hours was held, but the previous fire drill conducted during sleeping hours was not held within the required six-month interval.”

“Multiple residents' prescription medication labels did not accurately reflect the prescribed dosage and instructions for administration. One resident prescribed medication per sliding scale with instructions to call on-call nurse had a label indicating different dosing. Another resident prescribed one tablet by mouth in the afternoon had a label indicating two tablets in the morning and one in the evening. A third resident prescribed one tablet in the morning had a label indicating one tablet in the morning and one half tablet in the evening.”

“A resident prescribed medication per sliding scale with instructions to call on-call nurse had blood glucose measurements documented in the November 2025 Medication Administration Record (including 7:30 a.m. and 4:30 p.m. measurements), but these measurements could not be located in the device used to take the blood glucose measurements for the corresponding dates and times. Additionally, a narcotics log was not properly secured and was found in a medication cart located in a common hallway.”

“A resident's support plan completed does not address how the home will meet the resident's needs relating to diagnoses indicated on the resident's medical evaluation dated.”

“One resident's most recent support plan completed did not have a resident signature on the signature page, with the field left blank. Two other residents' most recent Assessment and Support Plan did not have dated resident signatures on the signature pages, with the fields left blank.”

“Direct care staff person A, who was hired, works in the Secured Dementia Care Unit but has not completed the required 6 hours of annual training related to dementia care and services in addition to the 12 hours of annual training.”

“Following an incident where a resident grabbed another resident's breast, this behavior was not added to the victim resident's support plan to address the need for additional assessment and protection.”

“A resident with a history of problematic behavior including sexually inappropriate acts grabbed another resident's breast and squeezed it. Staff observed the incident but the facility failed to prevent the abuse.”

“Resident's initial assessment did not address the resident's history of problematic behavior including sexually inappropriate acts as indicated on the preadmission screening form.”

“The home failed to immediately report suspected staff-on-resident abuse to the Area on Aging. Additionally, a suspected resident-on-resident abuse incident was not reported to the Area on Aging until approximately 10:00 a.m. the following day, rather than immediately.”

“After a staff member was suspected of abuse and suspended, the staff member returned to work and provided services to residents without an approved plan of supervision in place.”

“The home failed to report a suspected staff-on-resident abuse incident to the Department's personal care home regional office or complaint hotline within 24 hours as required.”

“Two residents had services implemented pertaining to unspecified diagnoses, but the most recent assessment and support plans did not indicate these services and were not updated to reflect the changes in residents' needs.”

“A resident prescribed an anxiety medication was not administered the medication for a 24-hour period because the medication was not available in the home, resulting in failure to follow the prescriber's orders.”

“The home did not report a suspected abuse incident to the Department within 24 hours as required. Staff observed another staff member administering an unknown substance via dropper to a resident's juice on 10/29/24, but the home did not report this to the Department until 10/31/24 at 2:25 PM.”

“A resident in the SDCU was administered unauthorized substances via dropper mixed into apple juice without medical orders, resulting in repeated vomiting. Staff members conspired via text messages to administer additional unauthorized medications to the resident. The resident is not prescribed these medications and they do not appear on the resident's medication administration record.”

“A resident in the SDCU was administered unauthorized substances (described as chemical restraints) via dropper mixed into beverages without medical orders. Staff conspired via text messages to administer additional unauthorized medications to control the resident's behavior, including attempts to sedate the resident.”

“Resident prescribed medication by mouth twice daily for pain was not administered medication from 9/20/2024 through 9/23/2024 at 8:00 a.m. Resident was discontinued on 9/23/2024 by nurse.”

“Resident support plan completed 7/13/2024 indicated behavioral/cognitive need of aggression as not applicable; however, on multiple dates including 9/10/2024, resident became verbally and physically aggressive with spouse and roommate resident, indicating significant condition change requiring additional assessment.”

“Staff failed to immediately report suspected abuse of a resident to the local Area Agency on Aging. Staff physically restrained a resident against her will while attempting to change her clothes, and the facility did not report this incident until after the inspection date.”

“The facility failed to report an incident of alleged abuse to the Department within 24 hours as required. The incident occurred on an unspecified date, but the facility did not report it to the Department until 01/22/2024 at 9:00 a.m.”

“Staff members physically restrained and held down a resident against her will while attempting to force her to change out of pajamas. The resident resisted, screamed for help, and was held down by multiple staff members on the bed.”

“Staff used manual restraint, a hands-on physical means that restricted and immobilized a resident's ability to move freely, which is prohibited. Multiple staff members held the resident down on the bed, restricting her movement while attempting to change her clothes against her will.”

“The facility failed to provide a system for safeguarding residents' property. Multiple residents reported money and jewelry items going missing from their rooms, but the home had not implemented protective measures such as lock boxes or locks.”

“A resident's assessment did not reflect a significant change in condition. The resident was assessed as independent for ambulation but subsequently had multiple falls requiring hospital admissions, indicating the assessment was not updated despite significant changes in the resident's condition.”

“Directions for operating the home's key-locking device were not conspicuously posted near the front entrance door to the Secure Dementia Care Unit (SDCU).”

“Medication administration records (MAR) for Resident #1 in August 2023 did not match the resident's prescribed medications and dosing instructions for multiple medications.”

“The last fire drill conducted during sleeping hours was on 11/15/22 at 10:45 pm. Fire drills during sleeping hours must be held once every 6 months.”

“Fire drills were routinely held when additional staff persons were present. The home's staffing schedule indicates 4 staff persons routinely work the 11:00 pm-7:00 am shift, but the home had not conducted a fire drill with the minimum number of staffing.”

“A discontinued medication (discontinued on 3/31/12) for Resident #1 was found in the refrigerator in the medication room. Only current prescription, OTC, sample and CAM medications may be kept in the home.”

“Medications for Resident #1 were opened but not dated with the open date. According to manufacturer's instructions, these medications expire 28 days after opening and must be stored in an organized manner under proper conditions.”

“Medication labels for Resident #1 had discrepancies between prescriber's labels and actual directions. Resident #1's labels indicated conflicting sliding scale and dosing instructions. Resident #2's label indicated apply 2 times a day but prescription stated 2 times a day as needed.”

“Resident #4 was admitted to the Secure Dementia Care Unit but the medical evaluation does not indicate the need for a SDCU placement. The evaluation must be completed within 60 days prior to admission and must document the diagnosis of Alzheimer's disease or other dementia and the need for SDCU care.”

“Resident #4 was admitted to the Secure Dementia Care Unit, but the initial support plan was not developed and documented within 72 hours of admission or prior to admission.”

“The support plan for Resident #4 does not adequately address the resident's specific service need for SDCU placement, supervision and assistance in mobility in the event of an emergency. Descriptions only indicated general levels like 'extensive' and 'moderate' without specific details.”

“The home failed to report an incident of suspected verbal abuse to the Department within 24 hours. On 9/15/23, staff person A verbally abused resident #1, calling them disgusting after the resident spit out medication mixed with yogurt. The incident was not reported to the Department until 10/5/23, a 20-day delay.”

“Resident #1 was verbally abused by staff person A during breakfast on 9/15/23. After the resident spit out medication mixed with yogurt, staff person A stated, "Did you really just spit your pills out at me, that's disgusting. You're disgusting and I am done with you."”