Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Parkview Care Center during CMS and state inspections, most recent first.
Dietary manager qualifications were not met for the food and nutrition service leadership role. The dietary manager stated she did not have a dietary manager certification, and her file showed she had enrolled in training but had not yet taken it. The facility’s dietitian worked under contract and was not in the facility full time, while the facility policy required a designated food and nutrition services director who met State requirements.
The facility failed to prepare puree diet food to the required consistency for residents on altered diets. Dietary staff observed puree beef that was dry, thick, and lumpy rather than smooth like applesauce, and the DON later acknowledged it was not the appropriate consistency even after broth was added. The facility policy stated puree foods must be smooth and free of lumps.
Failure to Assess Self-Administration of Bedside Medication: A resident with dementia, schizophrenia, and DM was observed keeping Nystatin at the bedside and said she used it PRN for thrush. Record review showed the Nystatin order had been completed, there was no current order or active diagnosis of thrush, and the chart lacked a self-administration evaluation and care plan for the medication. The DON stated the medication was from an old order and staff had not completed a self-administration assessment.
A facility failed to develop comprehensive care plans for two residents. One resident had an order for oxygen PRN and related equipment changes, but the record lacked an oxygen care plan. Another resident had epilepsy, mild cognitive impairment, and an order for Valproic Acid via G-Tube, but the record lacked a care plan for epilepsy or anticonvulsant monitoring; the DON and MDS Coordinator both acknowledged the missing plans.
A resident with CHF and diuretic orders did not have the required daily weight obtained, and the record later showed a 9-pound weight gain. The clinical record, including the eMAR, progress notes, and vitals, documented that the ordered weight monitoring was not completed as directed.
Improper oxygen services were identified for a resident receiving O2 at 2 L via NC. Staff observed the concentrator’s humidification bottle attached with no water present on two occasions, despite a physician order for PRN oxygen and weekly changes of the tubing, humidifier bottle, and nebulizer circuit. The resident had diagnoses including DM2 and atrial fibrillation, and the record lacked a care plan for oxygen use; the DON stated the humidification bottle should be full of water and filled as needed.
Medication administration observations identified an 8% error rate, with two errors in 25 opportunities. An RN administered Basaglar insulin to a resident with diabetes without priming the KwikPen first, and an LPN gave Advair to a resident with COPD without offering mouth rinsing after the inhalation, despite the order and manufacturer guidance.
Improper hand hygiene was observed during catheter care for a resident. Two CNAs washed their hands for only a few seconds at multiple points during the care, including before donning PPE, after the procedure, and before leaving the room. The IP stated staff were trained to wash hands for at least 40 seconds, preferably 60 seconds, and the facility’s hand hygiene procedure called for vigorous rubbing for at least 20 seconds.
Staff lacked adequate training on an external catheter device for a resident with urinary incontinence who required substantial assistance with toileting, hygiene, transferring, and nighttime catheter use. The resident reported that some staff did not know how to use the device, a CNA said she was unsure how to use it, and an LPN stated she had no formal education on the device; another LPN said training was informal and documentation of education was not available.
Surveyors found that multiple resident rooms and shared bathrooms had persistent urine odors, damaged flooring, debris, and cobwebs, despite daily cleaning routines. Residents expressed dissatisfaction with bathroom cleanliness and requested a deep cleaning schedule, while facility policy required maintaining a sanitary and comfortable environment.
Two residents admitted with wounds did not have immediate physician orders for wound care upon admission. One resident with multiple wounds, including a stage 2 pressure ulcer and a traumatic wound, experienced a delay in receiving specific treatment orders. Another resident with a recent above-knee amputation also lacked timely wound care orders, leading to concerns about missed dressing changes. Nursing staff confirmed that orders were not promptly obtained as required by facility policy.
The facility failed to properly store medications in four out of six medication carts, with loose pills found in the drawers of several carts, including Cherry Lane and Dogwood Lane. A bottle of water was also found in one cart. RN 5 confirmed that loose pills should not be present and should be placed in a drug buster. The facility's policy requires all medications to be securely locked and inaccessible to residents and visitors.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. A resident with a UTI lacked a care plan for infection and antibiotic use, while another on diuretics for edema had no plan for medication use or side effects. A resident with a treatment-resistant UTI and mobility issues also lacked appropriate care plans. Additionally, a resident on hospice care and diuretics, and another dependent on enteral feeding, were not adequately monitored or had care plans in place.
The facility failed to provide scheduled bathing and hygiene assistance to residents requiring help with ADLs. Several residents, including those with specific medical conditions like spinal muscular atrophy and COPD, did not receive showers or bed baths as per their care plans. Documentation showed numerous missed bathing opportunities, and staff cited time constraints and resident difficulty as reasons for non-compliance.
The facility failed to provide restorative nursing services to two residents with limited range of motion. One resident with spinal muscular atrophy and scoliosis did not receive planned passive ROM exercises, with documentation showing multiple days marked as 'not applicable' or 'resident refused.' Another resident with muscle weakness and dementia also missed active ROM exercises, with several days marked as 'not available' or left blank. The facility's policy required documentation of objectives and interventions, which was not consistently followed.
A facility failed to maintain an oxygen concentrator for a resident with COPD, as the filter was observed with dust on two occasions. The resident's records lacked documentation for cleaning the filter, contrary to the facility's policy requiring weekly maintenance. The DON confirmed the task should have been documented.
The facility failed to ensure complete documentation for two residents regarding falls. A resident with diabetes and COPD was found on the floor, and the neurological assessment was incomplete. Another resident with dementia and schizoaffective disorder experienced multiple falls, with missing vital signs and neuro checks. The DON confirmed that all documentation should be complete, as per the facility's Fall Management policy.
A facility failed to implement a communication process with hospice personnel, resulting in a lack of documented communication for a resident receiving hospice care. The resident's clinical record lacked a hospice care plan and documentation of communication between hospice and facility staff. Staff interviews revealed that not all were aware of the hospice provider's switch to an online portal, and access to hospice records was limited to certain staff members.
A facility failed to notify a physician and a resident's representative about changes in the resident's medical status, including new wounds and a UTI. The resident had multiple diagnoses and was dependent on staff for care. Documentation was lacking for notifying the physician and family about skin impairments and a UTI diagnosis, contrary to facility policies.
The facility failed to post accurate actual hours worked for nursing staff responsible for resident care for five out of six days during the survey period. Observations showed that the posted staffing sheets did not specify actual hours worked by LPNs, QMAs, and CNAs. The Director of Nursing confirmed the inability to determine actual hours from the sheets, contrary to the facility's policy.
Dietary Manager Lacked Required Qualification
Penalty
Summary
The facility failed to ensure the kitchen manager met the required qualifications for the food and nutrition service director role for 1 of 1 dietary manager qualifications reviewed. During interview, the dietary manager stated she did not have a dietary manager certification. Review of the employee file showed she had been employed since 10/15/14 and had enrolled in dietary manager training on 8/20/24, but had not yet taken it. The dietary manager also stated the dietician worked under contract and was not in the facility full time. The Administrator provided a policy titled Departmental Leadership Requirements, revised 4/16/24, stating that if a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who meets State requirements for food service managers or dietary managers.
Puree Diet Food Not Prepared to Required Consistency
Penalty
Summary
The facility failed to ensure food was prepared in a form designed to meet the individual needs of residents receiving a puree diet. During an interview, the dietary manager stated there were four residents on puree diets, including one resident receiving double puree portions, while a later diet order review indicated only two residents received puree altered foods. During observation, dietary staff prepared puree zucchini, puree noodles, and puree beef, but the beef was observed to be dry, thick, and lumpy rather than puree consistency. The dietary manager stated puree consistency should be similar to applesauce and later acknowledged the beef was not the appropriate consistency. She then added two cups of beef broth to the beef and returned it to the serving dish, but it was still observed to be thick with lumps. The facility policy stated puree foods should be blended, whipped, or mashed to a pudding-like texture and be smooth and free of lumps.
Failure to Assess Self-Administration of Bedside Medication
Penalty
Summary
The facility failed to ensure that a resident who was self-administering medication was assessed for the ability to self-administer medications. Resident 2 was observed in bed with a bottle of Nystatin on the bedside table and stated that she used it as needed to treat thrush in her mouth. The resident’s record showed diagnoses including dementia, schizophrenia, and diabetes mellitus, and the most current MDS indicated mild cognitive impairment, independence in eating and transferring, setup assistance for toileting and bathing, and no infections. Record review showed that the prior Nystatin order had been discontinued and completed, and there was no current order for Nystatin, no documentation of an active diagnosis of thrush, no care plan for self-administration of Nystatin, and no self-administration evaluation for the medication. During interview, the DON stated there was no self-administration evaluation for Nystatin and that the medication was from an old order, but the resident would not let staff remove it from the room. The facility policy stated that residents who request to self-administer medications are to be assessed by the IDT, with the assessment documented in the electronic medication record, and that the care plan should reflect self-administration when approved.
Missing Care Plans for Oxygen Use and Epilepsy Management
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 33 related to oxygen use. Resident 33 had diagnoses including type 2 diabetes mellitus, thoracic, thoracolumbar and lumbosacral intervertebral disc disorder, and atrial fibrillation, and the current MDS indicated the resident was cognitively intact and required partial to moderate assistance with toileting and dressing, and supervision with transferring. The physician orders included oxygen at 2 liters per minute via nasal cannula as needed for SPO2 less than 90%, and orders to change oxygen tubing, humidifier bottle, and nebulizer circuit weekly, but the record lacked a care plan for oxygen use. The DON stated there should be a care plan for oxygen. The facility also failed to develop a care plan for Resident 11 related to epilepsy and anticonvulsant medication monitoring. Resident 11 had a diagnosis of epilepsy, and the most current annual MDS indicated mild cognitive impairment and that the resident received an anticonvulsant during the 7-day lookback period. Physician orders included Valproic Acid Oral Solution 750 mg via G-Tube twice daily related to idiopathic epilepsy. Although a care conference was completed with the resident's family member and care plans were reviewed, the clinical record lacked a care plan related to epilepsy or monitoring of the anticonvulsant medication. The DON and MDS Coordinator both indicated that the resident should have had such a care plan, and the MDS Coordinator stated it would be added.
Failure to Follow Weight Monitoring and Physician Orders
Penalty
Summary
The facility failed to ensure physician orders were followed and failed to obtain a resident’s daily weight for 1 of 1 residents reviewed for hospitalizations. The resident was admitted with diagnoses including heart failure and had an admission MDS showing cognitive intactness, substantial assistance needed for toileting, and diuretic use. Physician orders required daily weights for 60 days, with notification to the MD/NP for a gain of more than three pounds in 24 hours or more than five pounds in seven days, and ordered Bumetanide for congestive heart failure. The clinical record, including the eMAR, progress notes, and vitals, showed the resident’s weight was not obtained on 11/15/25 and that a nine-pound weight gain was documented on 11/16/25.
Improper Oxygen Humidification and Missing Care Plan
Penalty
Summary
Failure to provide proper oxygen services according to physician orders was identified for one resident. Resident 33 was observed sitting in a wheelchair wearing oxygen at 2 liters via nasal cannula connected to a concentrator, and the concentrator had a humidification bottle attached with no water present. The next day, the resident was out of the room and the oxygen concentrator was again observed with the humidification bottle present and no water in it. Resident 33’s record showed diagnoses including type 2 diabetes mellitus, thoracic, thoracolumbar and lumbosacral intervertebral disc disorder, and atrial fibrillation. The resident’s current admission MDS indicated cognitive intactness and partial to moderate assistance with toileting and dressing, with supervision for transferring. Current physician orders included oxygen at 2 liters per minute via nasal cannula as needed for SPO2 <90%, and orders to change oxygen tubing, humidifier bottle, and nebulizer circuit weekly. The record lacked a care plan for oxygen use. The DON stated the humidification bottle should be full of water and filled as needed.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure it was free of a medication error rate greater than 5 percent during observation of medication administration, with 2 errors identified in 25 opportunities for an 8 percent error rate. One error involved RN 3 administering Basaglar KwikPen insulin to Resident 28, who had diagnoses including diabetes mellitus and was cognitively intact, without priming the insulin pen before giving the ordered 40 units subcutaneously. RN 3 stated the pen should have been primed with one or two units before setting the dose. The resident’s physician order called for Basaglar KwikPen 40 units twice daily, and the manufacturer’s instructions and facility insulin use policy both indicated the pen should be primed before each injection. The second error involved LPN 11 administering Advair Diskus to Resident 75, who had COPD and was cognitively intact, without offering or encouraging the resident to rinse his mouth after the inhalation. The resident had a physician order for Advair 250-50 mcg one inhalation twice daily with instructions to rinse the mouth after use. The manufacturer’s instructions stated the patient should rinse the mouth with water after inhalation to help reduce the risk of oropharyngeal candidiasis, and the facility’s dry powder inhaler policy also directed mouth rinsing after use.
Improper Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to ensure infection control practices and standards were followed during catheter care for one resident. On 12/10/25 at 9:03 A.M., two CNAs were observed providing catheter care for Resident 6, and hand hygiene was not performed correctly. Prior to donning gown and gloves, one CNA washed her hands for eight seconds. After completing the care and before emptying the catheter bag, she washed her hands for 12 seconds. After all care was completed and before leaving the room, she washed her hands for seven seconds, and the other CNA washed her hands for 13 seconds. During interview, the Infection Preventionist stated staff were trained to wash their hands for at least 40 seconds, preferably 60 seconds. The Administrator later provided the facility’s Hand Hygiene policy and the referenced hand hygiene procedure, which indicated hands should be vigorously rubbed together for at least 20 seconds.
Staff Lacked Training on External Catheter Use
Penalty
Summary
The facility failed to ensure that staff were adequately trained to use an external catheter device for one resident who was cognitively intact and required substantial maximum assistance for toileting, hygiene, transferring, and use of an external catheter appliance at night. The resident’s diagnoses included unspecified urinary incontinence, muscle weakness, and malignant neoplasm of the ascending colon. The physician orders directed staff to keep the external catheter appliance urine collection system level with the bed height each shift, connect the tubing and cannister per manufacturer instructions, turn the unit on, and replace the catheter every 8 hours. During interview, the resident stated that some staff did not know how to use the external catheter appliance. A CNA stated she was not sure how to use it, and an LPN stated she had no formal education on the device. Another LPN stated there was no formal education on the external catheter device and that training would be done individually with return demonstration, but there was no documentation of the education that was completed. The facility’s policy on Education and Training stated that staff must be trained to interact in a manner that enhances residents’ quality of life and quality of care and demonstrate competency in the training program topic areas.
Failure to Maintain Sanitary and Comfortable Resident Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents across all three units reviewed. Observations revealed strong urine odors in multiple resident bathrooms at different times of the day, as well as damaged and unclean flooring, including crumbling caulking, debris, cobwebs, and holes in linoleum. These issues were present in several shared bathrooms and resident rooms, indicating a widespread problem with cleanliness and maintenance. Interviews and record reviews further supported these findings. A housekeeper reported that resident rooms were cleaned daily, including dusting, sweeping, mopping, cleaning high-touch surfaces, removing trash, and cleaning toilets. However, resident council meeting minutes indicated ongoing dissatisfaction with the cleanliness of bathrooms, with requests for a deep cleaning schedule and specific complaints about the condition of bathroom floors. The facility's housekeeping policy required maintaining a sanitary, orderly, and comfortable interior, but the observed conditions did not meet these standards.
Failure to Obtain Immediate Wound Care Orders for Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that newly admitted residents with wounds had immediate physician orders for wound care, as evidenced by the cases of two residents. For one resident with a history of a displaced intertrochanter fracture, chronic pain, fibromyalgia, and recent surgeries, the admission records indicated the presence of a stage 2 pressure ulcer, a third-degree burn, and a non-healing surgical wound. Although care plans and wound observation tools documented these wounds and their characteristics, there was a delay in obtaining specific physician orders for wound care upon admission. The only documented order for the right inner ankle wound was initiated several days after admission, and it was later clarified that the wound was traumatic rather than pressure-related. Another resident, admitted following a right above-knee amputation due to vascular issues, also lacked immediate wound care orders upon arrival. The resident's care plan referenced the need for treatment and weekly skin checks, and progress notes indicated the use of betadine and Kerlix on the surgical stump. However, the facility did not have physician orders for wound care at the time of admission, and the orders were only received and implemented after a delay. The resident expressed concern about the lack of timely dressing changes, which was attributed to the absence of hospital-provided wound care orders and a delay in obtaining them from the physician. Interviews with nursing staff and the DON confirmed that it was the responsibility of the admitting nurse to obtain wound care orders if not provided by the transferring facility. The facility's policies required immediate assessment and treatment in accordance with professional standards, but in these cases, there was a failure to secure timely physician orders for wound care upon admission, resulting in a deficiency related to the immediate care needs of residents with wounds.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications in four out of six medication carts, as observed during a survey. Loose pills were found in the drawers of the Cherry Lane Medication Cart, Dogwood Lane Cart 1, and two carts on [NAME] Lane. Specific observations included various loose pills of different shapes and colors, such as small oblong white pills, broken pieces of peach pills, and small round pink pills, among others. Additionally, a bottle of water was found in the lower drawer of the Cherry Lane Medication Cart, which was acknowledged as inappropriate by RN 3 during an interview. RN 5 confirmed that there should be no loose pills in the carts and mentioned that any loose pills should be placed in a drug buster. The facility's policy on the storage and expiration dating of medications, revised on 8/7/23, was provided by the Administrator. This policy mandates that all medications must be securely locked in a cabinet or cart that is inaccessible to residents and visitors. The presence of loose pills and inappropriate items in the medication carts indicates a failure to adhere to this policy.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. Resident C, diagnosed with a urinary tract infection, was prescribed Keflex, an antibiotic, but lacked a care plan for the infection or antibiotic use. Similarly, Resident N, who was cognitively intact and required assistance for toileting, was on diuretics for edema but did not have a care plan addressing the use of these medications or monitoring for potential side effects. The Director of Nursing acknowledged the absence of these care plans. Resident L, with diagnoses including atrial fibrillation and diabetes, was being treated for a treatment-resistant urinary tract infection but lacked a care plan for the infection and antibiotic use. Additionally, there was no care plan addressing Resident L's mobility and assistance needs. Resident Z, who had a history of stroke and coronary artery disease, was taking antiplatelet and antianxiety medications but did not have corresponding care plans. The Director of Nursing indicated that a care plan for aspirin was not expected, but one for Ativan was. Resident J, receiving hospice care and diagnosed with heart failure and atrial fibrillation, was on a diuretic but lacked a care plan for its use. Resident V, dependent on enteral feeding, reported delays in feeding administration and had not been weighed since admission due to refusal, yet there was no alternative process for weight monitoring. The facility's policies on care plan development and changes in resident condition were not adequately followed, contributing to these deficiencies.
Failure to Provide Scheduled Bathing and Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents requiring assistance with Activities of Daily Living (ADLs) were bathed or assisted to bathe as needed. Resident V, who was completely dependent on staff for bathing, expressed a desire for more frequent complete bed baths than the once-a-week schedule provided. Documentation revealed numerous dates where Resident V did not receive a complete bath or shower, with no records of refusals. Similarly, Resident P, who required supervision for transfers and preferred showers twice a week, only received three showers in the last 30 days, all on Fridays, contrary to her scheduled days. Resident S, who needed substantial assistance with hygiene, reported not receiving bed baths on scheduled days. Documentation showed several missed bed baths over several months. Resident T, who required substantial assistance and preferred hair washing with bed baths, was observed with oily hair and reported infrequent hair washing. Records indicated multiple missed showers or bed baths with hair washing over several months. LPN 7 noted that Resident T was difficult to get up, which contributed to missed showers. Resident C, who preferred showers twice a week due to eczema, often received two bed baths instead of a shower and was observed with facial stubble despite a care plan for daily shaving. Documentation showed missed showers and bed baths on scheduled days. The DON indicated that shower sheets were not part of the clinical record, and all showers should be documented in the Point of Care (POC) Tasks. The facility's ADLs policy stated that residents unable to carry out ADLs should receive necessary services to maintain hygiene, which was not consistently followed.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services to residents with limited range of motion, as evidenced by the cases of two residents. Resident V, who has contractures of all extremities and diagnoses including spinal muscular atrophy and scoliosis, reported not receiving restorative nursing services during a week in September. The care plan for Resident V included passive range of motion exercises, but documentation showed multiple days marked as 'not applicable' or 'resident refused,' with no further documentation to explain the lack of services. The clinical record lacked sufficient documentation to account for the days when restorative nursing was not provided. Similarly, Resident 35, diagnosed with muscle weakness and dementia, was also on a restorative program that included active range of motion exercises. However, the documentation for Resident 35 showed several days marked as 'not available' or left blank, indicating a failure to provide the planned restorative services. The facility's policy required measurable objectives and interventions to be documented in the care plan and medical record, but this was not consistently done. The administrator confirmed that residents care planned for restorative nursing should receive services daily unless specified otherwise in the care plan.
Failure to Maintain Oxygen Concentrator for Resident with COPD
Penalty
Summary
The facility failed to ensure proper maintenance of an oxygen concentrator for a resident with chronic obstructive pulmonary disease (COPD), identified as Resident P. On two separate occasions, the oxygen concentrator's filter was observed to have moderate dust accumulation, indicating it had not been cleaned as required. The resident's clinical record did not include an order for cleaning the filter in the Treatment Administration Record, despite the facility's policy that required nurses to clean the filters weekly and as needed. The Director of Nursing confirmed that the task was expected to be documented, but it was not present in the resident's records.
Incomplete Documentation of Falls for Two Residents
Penalty
Summary
The facility failed to ensure accurate and complete documentation for two residents regarding falls. Resident P, who has diagnoses including diabetes mellitus and COPD, was found on the floor in her room, believed to have rolled out of bed. The clinical record for Resident P lacked a completed neurological assessment following the fall, with several time slots on the neurological checklist left blank without documentation. The Director of Nursing (DON) confirmed that a risk assessment and complete neurological checklist should have been completed after each fall event. Similarly, Resident 12, who has diagnoses including dementia disorder and schizoaffective disorder, experienced multiple falls. The neurological checklists for these falls were incomplete, with missing vital signs and neuro checks at various intervals. The DON acknowledged that all boxes on the Neurological Check List should be completed. The facility's Fall Management policy requires documentation of vital signs with any fall event, which was not adhered to in these cases.
Failure to Implement Hospice Communication Protocol
Penalty
Summary
The facility failed to establish and implement a communication process with hospice personnel, which resulted in a lack of documented communication between the long-term care facility staff and the hospice provider for a resident receiving hospice care. The clinical record of Resident J, who had diagnoses including heart failure and atrial fibrillation, did not contain a care plan related to hospice services or any documentation of communication between hospice staff and facility staff. Additionally, there was no hospice medical record within the resident's clinical record. Interviews with facility staff revealed that the hospice provider had transitioned to using an online portal for documentation, but not all staff were aware of this change. The Director of Nursing (DON) indicated that unit managers and the infection prevention nurse had access to the hospice portal using her login credentials. However, if the DON was not present, staff would have to contact her or the hospice directly to access the records. The facility's hospice policy required a written communication protocol to ensure the needs of hospice patients were addressed, but this protocol was not effectively implemented or communicated to all relevant staff.
Failure to Notify Physician and Family of Resident's Medical Changes
Penalty
Summary
The facility failed to notify the physician and resident representative of changes in a resident's medical status, specifically for a resident with skin conditions and a urinary tract infection (UTI). The physician was not informed of a new wound, and the resident's representative was not notified of the new wound, new diagnosis, and new medication order. A family member discovered a dressing on the resident's foot and additional sores on various parts of the body, prompting a request for a skin assessment. Despite the family suspecting a UTI, lab work had not been returned, and antibiotics had not been started. The clinical record review revealed that the resident had multiple diagnoses, including hemiplegia, aphasia, atopic dermatitis, and a UTI. The most recent Minimum Data Set (MDS) assessment indicated the resident was not assessed for cognitive impairment and was dependent on staff for various needs. The facility's records lacked documentation of a care plan for the UTI and did not show that the physician or resident representative had been notified of the skin impairments. Progress notes from the nurse practitioner did not include assessments or treatments for the identified skin impairments. The Director of Nursing (DON) confirmed that documentation of notifications to the physician and family was missing from the clinical record. The facility's policies required communication of changes in a resident's status to the appropriate practitioner and family, along with proper documentation. However, these procedures were not followed, as evidenced by the lack of notification regarding the resident's skin conditions and UTI diagnosis.
Inaccurate Posting of Nurse Staffing Hours
Penalty
Summary
The facility failed to post accurate actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift daily for five out of six days during the annual survey period. Observations on specific dates revealed that the posted nurse staffing data sheets did not specify the actual hours worked by staff members, including LPNs, QMAs, and CNAs. For instance, on one occasion, the sheet indicated that two LPNs worked 20 hours between 7:00 A.M. and 7:00 P.M. without specifying the actual hours worked. Similar discrepancies were noted for QMAs and CNAs on other days. The Administrator provided copies of the posted nurse staffing sheets for several dates, all of which failed to reflect the actual hours worked. The Director of Nursing confirmed the inability to determine the actual hours worked from the posted sheets. The facility's policy, revised in July 2023, requires posting the total number and actual hours worked by nursing staff at the beginning of each shift, which was not adhered to during the survey period.
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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.
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Nursing homes near Evansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Bend Nursing And Rehabilitation | 1.3 mi | ★★★★★ | 23 | 0 |
| Heritage Center | 1.3 mi | ★★★★★ | 0 | 0 |
| North Park Nursing Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Envive Of River City | 1.9 mi | ★★★★★ | 25 | 0 |
| Brickyard Healthcare - Woodbridge Care Center | 1.9 mi | ★★★★★ | 0 | 0 |
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