Parkwood Village

The facility failed to ensure the environment was free of obstructions and hazards. Specifically, four unsecured, free-standing oxygen tanks were found standing upright on the floor in a resident's room instead of being placed in a cylinder rack or crate.

The facility failed to maintain the environment free of hazards by allowing unsecured, free-standing oxygen tanks to be stored in a resident's room. Specifically, four full oxygen tanks were found standing upright and unsecured on the floor instead of being placed in a cylinder rack.

The facility failed to ensure the medication aide observed a resident take their medications before documenting the administration in the medication administration record. Specifically, three tablets of a resident's medication were found left unsupervised and unsecured in a medication cup on a sink countertop in the resident's room.

The facility failed to ensure the medication aide observed a resident take their medication before documenting the administration. This was evidenced by three tablets of a resident's medication being found unsupervised and unsecure in a room containing residents with dementia and wandering behaviors.

The facility failed to administer medications as ordered for 2 of 5 sampled residents. This included failure to provide medications for pain, high blood pressure, acid reflux, and constipation for one resident, and failure to provide two medications intended to treat mood disorders, depression, anxiety, and suicidal ideation for another resident.

The facility failed to ensure that documentation for 3 of 6 sampled medication aides confirmed completion of the state-approved 5-hour, 10-hour, or 15-hour medication aide training. Additionally, there was no documentation that Staff A had completed the required medication clinical skills validation checklist.

The facility failed to ensure proper medication administration, specifically regarding a missed medication. Staff required retraining on the rights of medication administration and proper documentation procedures.

The facility failed to maintain adequate oversight of medication administration records. Corrective actions included implementing a new order tracking system and increasing the frequency of medication record audits.

The facility needed to ensure the accuracy of narcotic counts. Staff were trained on the proper counting of narcotics, and new protocols were established for daily and weekly audits of the narcotic count book.

The facility failed to ensure immediate pharmacy notification following suspected drug diversion. New procedures were implemented to ensure the pharmacy is contacted immediately when suspected diversion or missing narcotics are reported.

The facility failed to ensure that 3 of 6 sampled medication aides had documentation for completing the required state-approved medication training. Additionally, one staff member lacked the required state-approved medication clinical skills validation checklist.

The facility failed to properly manage medication orders, requiring clarification orders to be sent to the facility. Staff required retraining on processing new orders and documenting the administration of medications.

The facility failed to ensure electronic medication administration records (eMAR) were accurate for 2 of 5 sampled residents. Specifically, there was no documentation that an injectable medication (Trulicity) was administered on certain dates in May and June 2023, despite orders and pharmacy records indicating the medication was dispensed and administered.