Aneta Parkview Health Ctr

Based on observation, review of professional reference, review of facility policy, and staff interview, the facility failed to store food and maintain kitchen equipment in a sanitary manner for 1 of 1 kitchen. Failure to properly store food, clean the ice machine, and maintain good repair of kitchen equipment may result in contamination of food and foodborne illness.Findings Include: The 2022 Food and Drug Administration (FDA) Food Code, reviewed 01/28/26, Chapter 3 Food, page 16 , Section 3-305 Preventing Contamination From the Premises, Section 3-305.11 stated, A. Food shall be protected from contamination by storing the food: . 2) Where it is not exposed to . dust, or other contamination.Review of the facility policy Sanitation and Safety Perishable Food Storage occurred on 01/28/26. This policy, revised in 1994, stated, 4. Refrigerator shelving will not be covered with . foil or other material because it interferes with air circulation.Observations on 01/25/26 and 01/27/26 showed the following in the main kitchen:* The ice machine chute covered in calcium build up.* The upright refrigeration unit had rusted and corroded shelving racks and the two lower racks were covered with tin foil.* The walk-in cooler unit had rusted and corroded free standing shelving units. * The upright freezer contained one unlabeled, undated, and open to air package of chicken patties. During an interview on 01/28/26 at 10:43 a.m., an administrative staff member (#1) confirmed shelving should be free of rust and corrosion and food should be stored properly.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents received adequate supervision and/or monitoring for 1 of 1 sampled resident (Resident #1) with an elopement. Failure to adequately monitor and supervise a resident with a known elopement risk placed the resident's health and safety at risk. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident.
Findings include:
This surveyor determined a deficient practice existed on 10/22/24. The facility implemented corrective action and completed staff education on 10/22/24.
Review of the facility policy titled Standards of Care and Practice occurred on 10/23/24. This policy, dated April 2018, stated, . Each of the following is part of the routine care provided by caregivers, unless otherwise directed. Complete rounds every 2-3 hours during the day and night.
Review of Resident #1's medical record occurred on 10/23/24 and included the diagnoses of generalized anxiety disorder, unspecified dementia, and schizoaffective disorder. The care plan, edited 10/22/24, stated, . I may try [sic] elope and have a history of sleep walking. Wanderguard: Due to being disorientation [sic], there are concerns I may try to elope or even sleep walk. Please help redirect me and ensure my safety. A physician's order, dated 09/30/24, stated, Check wanderguard placement each shift .
Resident #1's progress notes included the following:
* 09/30/24 at 4:05 p.m. Resident noted to be anxious, confused, and wandering in common area. Resident stated she is looking for her brother. Resident's brother told SS [social services] that resident is risk for elopement and has hx [history] of UTI [urinary tract infection] with confusion and anxiety. Wanderguard brace applied on R) [right] wrist.
* 10/22/24 at 1:00 a.m. Resident was anxious and confused this evening . sat one on one with resident in common area for awhile and resident calmed down, warm blanket given and walked resident back to her room and she laid down to go to sleep.
* 10/22/24 at 5:50 a.m. Resident set off the door alarm this evening. Resident also then this morning followed the exit signs to the employee exit and got out without sounding the alarm. Writer found resident when writer was coming in from grabbing something from writer's car. Resident confused and was looking for a way home.
During interviews on 10/23/24 an administrative nurse (#1) stated the facility investigation determined Resident #1 exited the building at 3:22 a.m. on 10/22/24 and staff returned the resident to the building at approximately 5:40 a.m. The staff member (#1) reported she expected night shift staff to complete rounds on residents every two hours at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m. She confirmed staff failed to complete rounds as expected, and failed to discover the resident's elopement in a timely manner.
Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions to ensure the deficient practice does not recur by:
* All staff were educated on 10/22/24 as to the importance of monitoring residents at risk of elopement and those who currently utilize wanderguards.
* The facility determined the wanderguard alarm system malfunctioned, and no alert sounded when Resident #1 exited the building. The facility contacted the alarm company immediately and reset the system to ensure proper functioning on 10/22/24.
* Audits of the wanderguard system and staff rounding began 10/22/24.

Based on observation and record review, the facility failed to provide care and services to aid the healing or prevent the development of pressure ulcers for 1 of 2 sampled residents (Resident #32) with a history of pressure ulcers. Failure to apply barrier cream after toileting may result in the development of new pressure ulcers.
Findings include:
Review of Resident #32's medical record occurred on all days of survey. Diagnoses included a history of a pressure ulcer to the right buttocks. A nurse's note identified, . 10/10/23 Care conference note: No skin concerns. Pressure ulcer to his bottom is a scab, healing nicely. Skin protectant applied to buttocks after toileting. Current physician's orders included, Skin protectant to be applied after toileting Every Shift Day, Evening, Night. The resident's current care plan stated, . Problem Start Date: 10/12/2023 I have the potential of skin breakdown because I am incontinent and I have a diagnosis of Dementia. Approach Start Date: 10/12/2023 Protective ointment to my buttocks after toileting.
Observation on 10/24/23 at 11:07 a.m. showed a certified nurse aide (CNA) (#1) assisted Resident #32 to the bathroom. Upon completion of toileting, the CNA failed to apply barrier cream to Resident #32's buttocks.
Observation on 10/24/23 at 4:34 p.m. showed a CNA (#2) assisted Resident #32 to the bathroom. Upon completion of toileting, the CNA failed to apply barrier cream to Resident #32's buttocks.

Based on record review, the facility failed to ensure a rationale and duration for the use of an as needed (PRN) psychotropic medication for 1 of 3 sampled residents (Resident #31) with a prn psychotropic. Failure to ensure a rationale and duration of prn medications places residents at risk for receiving unnecessary medications and experiencing adverse consequences related to their use.
Findings include:
Review of Resident #31's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, insomnia, and unspecified psychosis. Physician's orders included trazodone (an antidepressant) PRN at bedtime, initiated 09/16/22. Communication with the physician regarding renewals of the trazodone failed to identify a rationale for its continued use or indicate a duration (i.e., end date) for the PRN order.