Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Center For Advanced Rehab At Parkside, The during CMS and state inspections, most recent first.
An LPN provided suprapubic catheter care to a resident with a suprapubic catheter, CKD, recurrent UTIs, and severe cognitive impairment while the resident repeatedly cried out in pain, guarded the area, and had visible bleeding at the site. The nurse continued the procedure, did not stop to assess pain during care, and only asked about pain after finishing. The nurse then gave acetaminophen 650 mg without first confirming a current MAR order and used an older standing order instead of the current PRN pain order.
Surveyors found that PTAC air filters in several resident rooms on one hall contained a significant amount of gray, fuzzy particulate matter, indicating they had not been properly cleaned or maintained. The Maintenance Director confirmed the filters were soiled, acknowledged they required cleaning, and reported that filter cleaning had been tied to intermittent room deep-cleaning without a clearly defined frequency. The DON stated that PTAC filters should be serviced and cleaned because respiratory issues can arise from breathing dirty air filters, and facility policy requires the Maintenance Director to maintain schedules and documentation for routine inspection and maintenance of mechanical and electrical equipment.
PASARR Level II evaluations were not completed for two residents with qualifying mental health and cognitive diagnoses. One resident had bipolar disorder, dementia with behavioral disturbance, psychotropic meds, and ongoing psych consults, while the other had mood disorder, MDD, anxiety, severe cognitive impairment, verbal aggression, and psychiatric services ordered. Both residents were missing from the PASARR tracking list, and the SSD confirmed the Level II requests had not been submitted promptly.
A resident with COPD, shortness of breath, and dependence on supplemental O2 was observed receiving O2 via nasal cannula while the concentrator filter was visibly soiled with dust. The tubing was initially not dated, and no humidifier bottle was in use. On a later observation, the tubing was dated, but the filter remained dirty. Staff, including an LPN and the DON, confirmed the filter required cleaning or replacement and that the humidifier bottle was not present.
The facility failed to implement a proper surveillance plan for infections and antibiotic use, as the Infection Preventionist admitted to not actively monitoring the antibiotic stewardship program. The Director of Nursing, new to the position, was unfamiliar with the system needed to educate nurses on creating cases for antibiotic use in the EMR. This lack of coordination and communication among staff led to the deficiency.
The facility failed to adhere to medication administration standards for three residents. An LPN administered diclofenac gel without measuring the prescribed dosage, another LPN did not prime an insulin pen before use, and a resident was not instructed to rinse their mouth after using a Breztri inhaler. The DON confirmed the correct procedures were not followed.
Two residents in an LTC facility did not receive adequate assistance with ADLs due to staffing issues and poor documentation. One resident experienced delays in receiving help with catheterization, leading to hygiene issues, while another faced missed showers due to staff shortages. The facility's failure to document care activities contributed to the deficiency.
The facility exceeded the acceptable medication error rate with a 7.14% error rate due to three observed errors. An LPN failed to measure diclofenac gel correctly and did not prime an insulin pen before use. Additionally, the LPN documented administering a nasal spray that was not given. These actions contributed to the deficiency.
A resident with a BMI of 19.9 or less and experiencing weight loss reported that meals were often unpalatable, leading her to eat mostly Cheerios. She was not offered alternative meal options, and staff did not inquire about her lack of intake. Interviews with staff revealed gaps in communication and follow-up regarding the resident's meal refusals, contributing to the deficiency.
The facility failed to ensure proper hand hygiene and equipment sanitization during resident care. An LPN did not sanitize her hands before preparing medications or entering a resident's room, while another LPN failed to sanitize her hands before and after donning gloves during a blood glucose check and insulin administration. Additionally, a blood pressure monitor was not sanitized between uses for different residents. The DON confirmed that staff were expected to follow facility policies on hand hygiene and equipment cleaning.
Pain Not Assessed During Catheter Care and Medication Given Without a Valid Order
Penalty
Summary
The facility failed to ensure appropriate pain management and medication administration during suprapubic catheter care for one resident with severe cognitive impairment, obstructive and reflux uropathy with a suprapubic catheter, recurrent UTIs, chronic kidney disease, and acute kidney injury. During an observation, an LPN provided catheter care while the resident was in bed on oxygen therapy. As the nurse cleansed the suprapubic catheter insertion site with gauze and solution, the resident repeatedly cried out, stated that it hurt, turned away, pulled inward, and guarded the lower abdomen. Blood was visible on the gauze with each cleansing stroke, and the resident continued to show distress as the nurse manipulated and pulled on the catheter tubing. Despite the resident’s repeated pain responses, the nurse continued the procedure and did not stop to assess the resident’s pain during care. The nurse acknowledged the resident’s pain but completed the catheter care before asking whether the resident wanted something for pain. After the procedure, the resident said he was hurting, and the nurse left to obtain medication without performing a formal pain assessment, including no pain scale, no assessment of location, severity, or characteristics of pain, and no documentation of a pain assessment at that time. The nurse stated that the resident cries out in pain during catheter care and that pain medication is given only about once a week, even though catheter care is ordered daily. The nurse then administered acetaminophen 650 mg without first ensuring a valid current order was entered into the MAR and without following the current standing order instructions. The medication was given before the order was entered into the MAR, and the dose was based on an older, obsolete standing order rather than the current standing order for Tylenol Extra Strength two tablets every six hours as needed for pain or fever. The resident’s care plan included catheter care, pain assessment each shift, and pain medication as ordered, and the physician’s orders included pain assessment every shift and acetaminophen as needed for pain or elevated temperature. The DON confirmed that staff were expected to stop procedures when residents express pain, assess pain before, during, and after care, and verify orders before medication administration.
Failure to Maintain Clean PTAC Air Filters in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain Packaged Terminal Air Conditioner (PTAC) units in a safe, sanitary, and functional condition in multiple resident rooms on the [NAME] Hall. During observations on 4/21/2026, PTAC air filters in three separate rooms were found to contain a significant amount of gray, fuzzy particulate matter. On 4/22/2026, during a follow-up observation with the Maintenance Director, he confirmed that the PTAC air filters in the identified rooms were soiled with a significant accumulation of particulate matter and acknowledged that the filters required cleaning. The Maintenance Director stated that PTAC filter cleaning was assigned to the Environmental Services Director and was supposed to occur during room deep-cleaning, but he could not specify the exact frequency of these cleanings. He also stated that he had oversight responsibility for ensuring the task was completed and that the cleaning schedule might need review and adjustment. The DON stated that PTAC filters should be serviced and cleaned, as respiratory issues can arise from breathing dirty air filters. The facility’s policy titled “Physical Environment: Electrical Equipment” stated that the facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition and that the Maintenance Director shall maintain schedules for routine inspection and maintenance of such equipment, with documentation kept for at least three years.
PASARR Level II evaluations not completed for two residents with qualifying diagnoses
Penalty
Summary
The facility failed to ensure that PASARR Level II evaluations were submitted for two sampled residents, R3 and R7, who had diagnoses and clinical histories that met criteria for PASARR review. Record review, staff interviews, and resident interviews showed that both residents had qualifying mental health or cognitive diagnoses and were receiving psychiatric-related services and psychotropic medications, yet neither resident was included on the facility’s PASARR Level II tracking list and no PASARR Level II determination was found in the EMR. R3 was admitted after a lithium overdose related to bipolar disorder and reported needing better medication regulation. Her record showed diagnoses including bipolar disorder, dementia with behavioral disturbance, altered mental status, disorientation, and cognition/communication deficit. Her MDS reflected moderate cognitive impairment, and her care plan addressed mood instability, agitation, verbal aggression, confusion, wandering risk, insomnia, and psychotropic medication use. Physician orders included Depakote, olanzapine, citalopram, trazodone, behavior monitoring, antipsychotic monitoring, and psychiatric services, and psychiatric consults documented ongoing bipolar disorder management and continued monitoring needs. Despite this, the facility had no evidence of a PASARR Level II evaluation for R3 until the Social Services Director confirmed during interview that the request would be submitted that day. R7’s record showed diagnoses including mood disorder, major depressive disorder, anxiety disorder, and altered mental status. Her MDS showed severe cognitive impairment, and her care plan addressed verbal aggression toward staff and impaired cognitive function due to intellectual disability. Physician orders included sertraline, quetiapine, and psychiatric services to evaluate and treat as indicated, and psychiatric consults documented ongoing mood disorder management and continued monitoring for mood and behavior instability. The Social Services Director confirmed that R7 had qualifying diagnoses for PASARR Level II and stated that the request had not been submitted promptly and would be submitted on the date of interview.
Dirty Oxygen Filter and Missing Humidifier Bottle
Penalty
Summary
The facility failed to ensure proper maintenance and monitoring of oxygen equipment for one resident receiving supplemental oxygen. The resident had diagnoses including COPD, shortness of breath, and dependence on supplemental oxygen, and had physician orders for oxygen at 3 L/min via nasal cannula with monitoring for respiratory distress and oxygen therapy as ordered. During an observation, the resident was lying in bed receiving oxygen via nasal cannula at 4 L/min, and the oxygen concentrator filter was visibly soiled with dust. The nasal cannula tubing was not dated, and no humidification device was observed in use with the oxygen delivery system. On a later observation, the resident was again receiving oxygen via nasal cannula, with the flow rate at 3 L/min and the tubing dated, but the oxygen concentrator filter remained visibly dirty with no evidence of cleaning or replacement. Staff interviews reflected that tubing was expected to be changed and dated weekly and that concentrator filters were to be checked, cleaned, or replaced on a weekly basis. The CNA stated oxygen tubing was kept in a plastic bag in the resident's room, and the LPN confirmed the humidifier bottle was not present and the filter required cleaning. The DON also confirmed the filter was dirty and required cleaning or replacement.
Deficiency in Antibiotic Stewardship and Infection Control
Penalty
Summary
The facility failed to properly establish and implement a surveillance plan for identifying, tracking, monitoring, and reporting infections and antibiotic use among residents and staff. The facility's policy on Antibiotic Stewardship Program required nursing staff to assess residents suspected of having an infection and complete an SBAR form before notifying the physician. It also required monitoring the response to antibiotics and reviewing laboratory results to determine if adjustments were needed. However, the Infection Preventionist (IP) admitted that there was no active monitoring of the antibiotic stewardship program, and documentation was not accurate. The IP did not reconcile antibiotic orders with the pharmacist or doctor and did not closely monitor labs or cultures to avoid unnecessary antibiotic use. The Infection Preventionist revealed that the surveillance process was incomplete due to nurses not performing their part, and there was no system set up to monitor lab results or antibiotic use effectively. The Director of Nursing (DON), who had been in the position for six weeks, was informed about the need to educate nurses on creating a case for antibiotic use in the electronic medical record (EMR) but was unfamiliar with the system. The DON expected the IP to pull records daily for antibiotic information but was unsure of the process. This lack of coordination and communication among staff led to the deficiency in the facility's infection prevention and control program.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to accepted standards of quality care during medication administration for three residents. For one resident, an LPN administered diclofenac gel without measuring the prescribed dosage, admitting unfamiliarity with the correct measurement process. The LPN did not use the provided measuring card, which was necessary to ensure the correct dosage of 4 grams was applied. The Director of Nursing confirmed that the correct procedure was not followed. Another deficiency involved an LPN administering insulin without priming the insulin pen, which is required to ensure accurate dosing. The LPN mistakenly believed priming was unnecessary for a newly opened pen and admitted to being nervous during the process. Additionally, a third resident was not instructed to rinse their mouth after using a Breztri inhaler, a necessary step to prevent potential side effects. The LPN acknowledged forgetting this step, and the Director of Nursing confirmed the importance of this practice.
Inadequate ADL Assistance and Documentation for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, R77 and R97, who were dependent on staff for such care. R77, who had a range of medical conditions including muscle weakness and bladder dysfunction, reported that she often had accidents at night due to insufficient staff response to her call bell. She mentioned that on weekends and nights, there was only one floor tech and one nurse available, leading to delays in assistance. This lack of timely care resulted in her waking up with dried urine on her clothes and bed, which she believed contributed to an itch in her private area. R97, who had a history of fractures and heart disease, expressed frustration over missed showers, particularly on weekends. She reported that her showers were often postponed due to staff shortages, and on one occasion, she went nine days without a shower. Despite being scheduled for showers on specific days, there was no documentation to confirm that these were consistently provided. The lack of proper documentation and adherence to the shower schedule was confirmed by the staff, including the CNA and RN responsible for R97's care. The facility's Director of Nursing and other staff acknowledged the expectation that all residents should receive the care they deserve daily. However, the report highlighted inconsistencies in staffing and documentation, particularly on weekends, which led to the deficiencies in providing necessary ADL support to residents R77 and R97. The absence of documentation for showers and the failure to respond promptly to call bells were significant factors contributing to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.14% due to three medication errors observed out of 42 opportunities. One incident involved an LPN administering diclofenac gel 1% to a resident's knees without measuring the prescribed 4 grams using the provided dosing card. The LPN admitted to not knowing how to measure the gel correctly and acknowledged that the pharmacy had not provided guidance on measurement. Upon suggestion, the LPN retrieved the measuring card from the medication packaging and admitted it should have been used to ensure accurate dosage. Another incident involved an LPN administering insulin using an insulin pen without priming it beforehand, as required by both facility policy and manufacturer instructions. The LPN stated that she did not think priming was necessary for a newly opened pen and was also nervous. Additionally, the same LPN documented administering fluticasone nasal spray to a resident but failed to actually administer it. She admitted to marking it as given and stated she would administer it immediately upon realizing the error.
Failure to Provide Palatable and Safe Meals to Resident
Penalty
Summary
The facility failed to provide a resident, identified as R77, with food and drink that was palatable, attractive, and at a safe and appetizing temperature. This deficiency was identified through observations, interviews with the resident and staff, and a review of the facility's nutritional management policy. The resident, R77, who had a BMI of 19.9 or less and was experiencing abnormal weight loss, reported that the food was often unpalatable, leading her to eat mostly Cheerios when the meals were unsatisfactory. She was not offered alternative meal options when she refused the provided food, and no staff inquired about her lack of intake or offered other choices. R77's medical records indicated several health issues, including weakness, muscle wasting, and difficulty walking, which necessitated ongoing physical therapy. Her care plan highlighted potential nutritional problems and included interventions such as monitoring intake, providing supplements, and encouraging compliance with the diet. Despite these measures, R77 reported not receiving a menu or being informed of available food alternatives, which contributed to her reliance on Cheerios as a substitute for meals she found unappealing. Interviews with facility staff, including a Registered Dietician (RD) and a Certified Nursing Assistant (CNA), revealed gaps in communication and follow-up regarding R77's meal refusals. The RD stated that food preferences were documented upon admission, but she was unaware of any meal refusals by R77. The CNA mentioned offering alternatives when residents refused meals, but there was uncertainty about whether this practice was consistently followed by all staff. An LPN also indicated a lack of awareness regarding R77's meal refusals, suggesting a breakdown in communication and documentation of the resident's dietary needs and preferences.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitization
Penalty
Summary
The facility failed to consistently perform hand hygiene procedures and sanitize shared medical equipment during care for residents. An LPN was observed preparing medications for a resident without sanitizing her hands before starting the task, after retrieving a missing nasal spray, and before entering the resident's room. She only sanitized her hands upon leaving the room. Another LPN was observed performing a blood glucose check and insulin administration for a resident without sanitizing her hands before donning gloves and after removing them. She only washed her hands after completing the task. Additionally, an LPN was observed using a blood pressure monitor on a resident without sanitizing it before or after use. The monitor was placed in her pocket and used again for another resident without cleaning. The LPN did not sanitize her hands upon entering the room or clean the shared equipment between residents' use. The Director of Nursing confirmed that staff were expected to practice frequent hand hygiene and ensure proper cleaning of shared equipment, as per facility policies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 63 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rossville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Fort Oglethorpe | 1.4 mi | ★★★★★ | 8 | 0 |
| Nhc Healthcare Ft Oglethorpe | 2.2 mi | ★★★★★ | 2 | 0 |
| Nhc Healthcare Rossville | 2.4 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of East Ridge | 4.6 mi | ★★★★★ | 6 | 0 |
| Nhc Healthcare, Chattanooga | 6.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Center For Advanced Rehab At Parkside, The.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.