Parkvue Place

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure the kitchen was maintained in a sanitary manner. This had the potential to affect all 35 residents in the facility. The facility census was 35.

Findings include:

Observation on 11/12/25 at 11:24 A.M. of the kitchen revealed a build-up of a white substance on top of the ice machine. Inside of the hood of the ice machine were black and brown spotted areas, and the screws that held the lid were rusted and dripping into the ice. On the wall behind the ice machine was splattered, dried food.

Interview on 11/12/25 at 11:25 A.M. with Dietary Service Manager (DSM) #100 verified the ice machine had a white substance build up, inside the hood of the ice machine had black and brown spotted areas, and the screws that held the lid were rusted and dripping into the ice. DSM #100 stated that the area behind the ice machine should be cleaned weekly and further confirmed there were food particles on the wall behind the ice machine.

Observation on 11/12/25 at 11:30 A.M. of the steam table revealed food, and other unknown particles, were floating in the water in the steam table. Concurrent interview with DSM #100 confirmed the steam tables had food and unknown particles floating in the water. DSM #100 further stated that the steam tables should be cleaned daily.

Observation on 11/12/25 at 11:33 A.M. of the drain under the tilt skillet and fryer revealed a large amount of food particles and a thick, black layer of an unknown substance throughout the drain. Concurrent interview with DSM #100 revealed that after staff use the tilt skillet, food particles were put into the drain. DSM #100 was unsure of when the drain was last cleaned and confirmed the excessive food and black substance build up was not sanitary.

Review of the facility policy titled, Food Safety- Director of Food and Nutrition Services Responsibilities, dated 2019, revealed sanitary conditions would be maintained in the food storage, preparation, and serving areas. Employees would follow proper cleaning and sanitizing instructions for all kitchen equipment. The Director of Food and Nutrition Services or designee would conduct regular inspections. Cleaning schedules would be posted and followed, and proper waste disposal methods would be used.

This violation is continued non-compliance to the annual survey completed 02/12/25.

Based on review of the facility fire drills, staff interview, and review of the facility policy, the facility failed to ensure fire drill evaluations were completed. This had the potential to affect all 35 residents residing in the facility. The facility census was 35.

Findings include:

Review of the facility fire drills revealed fire drills were completed on 02/28/25, 03/28/25, 04/29/25, 06/30/25, 07/31/25, 08/28/25, 09/30/25, and 10/30/25. Further review revealed no evidence an evaluation was completed after each of the drills. Concurrent interview with Director of Maintenance (DOM) #200 confirmed evaluations of the fire drills were not completed.

Review of the facility policy titled, Fire Drills, undated, revealed that during fire drills, staff knowledge was evaluated and the committee was responsible for evaluation of drills and suggestions for improvement.

Based on record review and interview, the facility failed to ensure skills training for a resident care assistant was evaluated by a licensed nurse prior to providing resident care. This had the potential to affect all residents. The facility census was 38.

Findings include:

Review of the personnel file for Resident Care Assistant (RCA) #192 revealed a hire date of 11/19/24. There was no documentation RCA #192 had completed skills training with a licensed nurse prior to providing resident care.

During an interview on 02/12/25 at 8:33 A.M., with the Human Resource Manager (HRM) # 240 stated RCA #192 had not completed a skills competency with a licensed nurse prior to providing resident care. RCA #192 trained with certified nursing assistants.

Based on observation and interview, the facility failed to ensure a resident was observed taking medications. This affected one (Resident #7) of two residents observed for medication administration.

Findings include:

During an observation on 02/11/25 at 8:25 A.M., Licensed Practical Nurse (LPN) #184 administered medications to Resident #7 in the dining room. LPN #184 left the residents medications on the table, not observing the resident take the medications.

During an interview at the time of the observation, LPN #184 verified she did not remain with the resident after administering medications. LPN #187 revealed she thought it was okay to leave the medications with the resident if she was in the same room.

Based on observation and staff interview, the facility failed to ensure the dryers were maintained to prevent a build up of lint. This had the potential to affect all residents. The facility census was 38.

Findings include:

During an observation on 02/11/25 at 8:59 A.M., the laundry rooms on the first, second, and third floors had a buildup of dryer lint and debris behind the washing machines and the dryers.

During an interview on 02/11/25 at 4:33 P.M.,the Administrator and the Director of Maintenance (DOM) #200 verified the above findings.

Based on record review, observation, interview and policy review, the facility failed to ensure residents were provided adequate portion sizes. This had the potential to affect all residents. The facility census was 38.

Findings include:

Review of the undated menu for week two Tuesday revealed the lunch meal would include four ounces of the vegetable of the day and four ounces of mashed sweet potatoes.

During an interview on 02/11/25 at 8:47 A.M., Dining Services Manager (DSM) #150 stated the menu had changed to include rice instead of mashed sweet potatoes.

During an observation on 02/11/25 at 11:44 A.M., Chef #172 used tongs to pick up green beans and a regular serving spoon for the rice to place the food on the plates.

During an interview on 02/11/25 at 11:46 A.M., Chef #172 revealed he eyeballed the serving sizes and had been doing it for a long time.

During an interview on 02/12/25 at 8:03 A.M., Dietary Director (DD) #199 revealed a four ounce spoodle should have been used to serve the green beans and a number eight scoop should have been used to provide a four ounce serving of rice.

Review of the facility policy Portion Control

Based on observation, interview, and policy review, the facility failed to ensure food items were labeled and dated and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents. The censes was 38.

Findings include:

1. During an observation on 02/11/25 10:54 A.M., the dry storage room contained open containers and bags of crushed peppermint, dried fruit, frosting, powdered sugar, Butterfingers crushed pieces, and crispy fry mix with no open date or expiration date. In the walk-in freezer there were a bag of open hash browns and opened bag of fried okra with no open date. Observation of the walk-in refrigerator revealed there was an open bag of lettuce and an open container of parmesan cheese with no open date. Observation of the reach in refrigerators revealed an open bottle of ranch dressing and two containers of orange juice with no open date. A container labeled blue cheese contained poppy seed dressing and did not have an open date.

During an interview on 02/11/25 at 10:54 A.M., Dietary Service Manager (DSM) #150 verified the undated food items at the time of observation.

2. During an observation on 02/11/25 at 11:22 A.M., there were five vents on the ceiling above the food preparation areas with built up dust, rust, and a black substance on the vents and on the ceiling surface surrounding the vents. The top of the dishwasher had a buildup of debris. Hanging food service utensils had dried food particles on them. Dietary Director (DD) #199 had prepared a bucket of sanitizer with the test strip registering no sanitizer present. Observation of the stove revealed a buildup of food debris in the drip tray below the cooking surface.

During observation of the meal service on 02/11/25 at 11:49 A.M., Chef #172 was not wearing a beard covering while plating food.

During an interview on 02/11/25 at 11:22 A.M., DD #199 and DSM #150 verified the findings at the time of the observation. DD #199 stated the automatic sanitizer dispenser was not functioning and would contact the service company.

Review of the facility policy titled Food Safety and Sanitation, dated 2019, revealed food items should be labeled with open dates and expiration dates when opened. Beard nets were required when facial hair was visible.

Review of the facility policy titled General Sanitation of Kitchen, dated 2019, revealed food and nutrition services staff would maintain the sanitation of the kitchen.

Based on record review and interview, the facility failed to ensure residents were evacuated during third shift fire drills and failed to ensure the alarm transmission signal of one fire drill. This had the potential to affect all residents. The facility census was 38.

Findings include:

Review of the third shift fire drill reports dated 01/24/24, 04/30/24, 07/31/24, 10/31/24,and 01/31/25 revealed no residents were evacuated during third shift fire drills.

Review of the fire drill report dated 05/30/24 at 11:30 A.M. revealed the fire alarm was pulled. However, review of the alarm transmission receipt for 05/30/24 revealed no signal was received at 11:30 A.M..

During an interview on 02/11/25 at 2:42 P.M., Director of Maintenance (DOM) #200 verified there was no receipt of the alarm transmission for the fire drill on 05/30/24 at 11:30 A.M..

During an interview on 02/12/25 at 11:30 A.M., the Administrator verified no residents were evacuated during third shift fire drills.

Based on observation and interview, the facility failed to maintain the facility in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 38.

Findings include:

During an observation on 02/11/25 at 8:53 A.M. there were black water spots on the ceiling by the first floor by garage one and two. The furnace at the end of the hall by garage 11-12 revealed rust stains and a buildup of debris along with a black substance on the vent. The furnace at the end of the hall by room 128 had black buildup on the vent. On the other side of the wall by room 128, another furnace was coated in a brown liquid. At the end of the hall by room 117 the stairwell door had fingerprints and brown liquid dripping down it. On the second floor by room 208 there was a 26 inch by six inch water stain on the ceiling with a 20 inch strip of peeling drywall in the center of the water stain. On the third floor there was a water stain on the ceiling between room 324 and 326.

During an interview on 02/11/25 at 4:15 P.M., the Administrator and the Director of Maintenance (DOM) #200 verified the findings.

Based on observation, interview and policy review, the facility failed to ensure chemicals were stored in a secure area. This had the potential to affect 10 (Residents #1, #5, #10, #11, #13, #22, #23, #33, #34, #38) who the facility identified as cognitively impaired and independently mobile. The facility census was 38.

Findings include:

During an observation on 02/11/25 at 9:25 A.M., the unlocked activity room had a mobile cleaning cart containing a bottle of all purpose cleaner. On the third floor in the exercise area there was one bottle of disinfectant sitting on the window ledge.

During an observation on 02/11/25 at 4:25 P.M., the unlocked activity room had the mobile cleaning cart observed earlier in the morning and had a second mobile cleaning cart contained toilet bowl cleaner and bottles of disinfectant.

During an interview on 02/11/25 at 4:25 P.M., the Administrator and the Director of Maintenance (DOM) #200 verified the bottles of disinfectant and toilet bowl cleaner in the unlocked activity room and exercise area on the third floor.

Review of the facility policy titled Hazardous Chemical Security, undated, revealed all hazardous chemicals and materials will be stored in a locked area when not in use.

Based on observation, staff interview, and policy review, the facility failed to hold foods on a salad bar at safe serving temperatures. This had the potential to affect 36 of 36 residents residing in the facility. The census was 36.

Findings include:

Observation of the salad bar on 05/02/24 at 11:17 A.M., revealed the following temperatures: Cole slaw 43 degrees Fahrenheit, cottage cheese 50 degrees Fahrenheit, chicken salad 52 degrees Fahrenheit, tuna salad 50 degrees Fahrenheit,yogurt 48 degrees Fahrenheit, eggs 48 degrees Fahrenheit, ham 49 degrees Fahrenheit, and shredded cheese 51 cheddar degrees Fahrenheit.

Interview on 05/02/24 at 11:17 A.M., with Dietary Director #405, verified the holding temperature for the salad bar were not in the safe holding temperatures.

Review of the policy titled, Handling Cold Foods for Tray Line, dated 2009, revealed cold food temperatures will be taken and recorded prior and halfway through the service to assure food is less than or equal Fahrenheit.

This violation is an example of the continued noncompliance from the survey dated 01/19/22.

Based on record review and staff interview, the facility failed to ensure fire drills were conducted on every shift every three months and residents were evacuate at least on two fire drills on each shift a year. This had the potential to affect all 36 of 36 residents residing in the facility.

Findings include:

Review of facility fire drill records from 04/01/23 through 04/30/24 revealed drills were conducted on the first shift: 05/29/23, 08/30/23, 11/30/23, and 02/29/24; on second shift: 09/26/23, 12/27/23, and 03/28/24; and on third shift: 04/27/23, 07/28/23, 10/30/23, 01/24/23 and 04/30/24. There was no drill for June 2023.

Further review of the drills conducted revealed no residents were documented as participating in an evacuation on at least two fire drills per year on each shift.

Interview on 05/02/24 at 3:50 P.M., with Maintenance Director #511 verified he has not included evacuation drills of residents for any of the fire drills conducted. Maintenance Director #511 verified he could not find a documented drill for June 2023.