Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Parkview Heights Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A facility inaccurately coded the MDS for four residents by recording Plavix as an anticoagulant during the assessment look-back period. EMR review showed each resident had an order for Plavix 75 mg daily for diagnoses including atherosclerosis, cerebral infarction, and atherosclerotic heart disease, and the LRN/MDS confirmed the MDS was coded incorrectly because Plavix is not an anticoagulant.
Failure to assist a resident with ADLs and oral hygiene: A resident with dementia, severe cognitive impairment, and dependence for personal hygiene was repeatedly observed with a dried brown film on her lower lip while sitting in common areas and the dining room. Staff interviews showed confusion about whether the material was dried blood or related to a sore in her mouth, and an LN and administrative nurse stated staff should have wiped her lips, but this was not done.
Failure to Implement Resident-Centered Fall Interventions: Three residents with dementia, severe cognitive impairment, and documented fall risk continued to experience falls despite care plans calling for call lights, close observation, toileting assistance, and other safety measures. One resident had repeated recliner-related falls and serious injuries, another fell from a recliner and was later transported in a wheelchair without foot pedals while staff gave inconsistent accounts of the plan, and a third had falls despite hourly rounds and a bedside reminder sign that was not in place during observation.
A resident with vascular dementia and dysphagia, who required meal assistance and was on a mechanical soft diet, was repeatedly not provided breakfast while staff documented him as asleep, unavailable, or refused. He was observed in a recliner with dry dentures and no breakfast offered, and staff later acknowledged he should have been given breakfast when awakened. Records also showed significant unplanned weight loss and reduced intake, with the RD noting he was sleeping more and not eating as well.
An LPN administered 30 units of Lantus insulin to a resident who was not diabetic and had severe cognitive impairment. The LPN immediately realized the error and notified the on-call physician; the resident’s blood sugar was monitored overnight and remained stable, with no negative outcome reported. Administrative Nurse C stated staff were expected to administer medications as ordered.
A resident with dementia and severe cognitive impairment was ordered a mechanical soft diet with nectar-thick liquids, but staff repeatedly provided regular thin liquids instead. Surveyors observed thin juice and water in front of the resident during meals, and staff confirmed the liquids were not nectar thick even though they knew the resident was supposed to receive nectar-thick fluids.
Staff failed to follow infection control practices during resident care and linen transport. CNAs did not use EBP PPE or perform hand hygiene while assisting a resident with open knee wounds, a nurse did not perform hand hygiene during a dressing change, and staff providing perineal care to another resident used gloved hands to handle room items and changed gloves without hand hygiene. Laundry staff also transported clean clothes on an uncovered cart and hugged them against a uniform, and nurses were observed handling items and giving insulin without proper hand hygiene.
COVID-19 Vaccine Offer and Documentation Deficiencies: A resident's EMR lacked documentation that the COVID-19 vaccine had been offered since 2022, and the facility failed to maintain staff records for screening, education, vaccine offering, and current COVID-19 vaccination status. An infection prevention nurse stated the facility did not keep this staff documentation, despite its policy requiring residents and staff to be offered the vaccine and staff education and offer records to be maintained.
The facility failed to submit accurate staffing information to CMS, missing 24-hour Licensed Nurse coverage on several dates in 2023 and 2024. An interview revealed possible inaccuracies in reporting actual hours worked by licensed nurses, despite a policy requiring accurate submissions.
The facility failed to complete comprehensive assessments and develop care plans for four residents, as required by the MDS and CAAs. Residents with severe cognitive impairments and various medical conditions did not have their care needs fully assessed, potentially leading to uncommunicated needs. The facility did not develop CAAs for areas such as Cognitive Loss/Dementia, Mood State, and Pain, despite these being triggered by the MDS.
A resident with sleep apnea using a CPAP machine did not have a comprehensive care plan addressing its use. The facility's records lacked a physician's order for the CPAP, and the care plan did not include instructions for staff on its use and care. Observations showed the CPAP mask was not cleaned between uses, confirmed by the resident, indicating a deficiency in care planning.
A resident with severe cognitive impairment and dementia was not properly positioned in her specialized wheelchair, as her feet were observed dangling above the footrest on multiple occasions. Despite facility policy requiring staff training on assistive devices, the resident's feet did not always reach the footrest, indicating a failure to ensure proper positioning.
The facility failed to ensure safe transfers for two residents with severe cognitive impairments, as they were not provided with non-skid footwear and mechanical lifts during transfers. Additionally, a resident requiring wheelchair assistance was not safely transported, as her feet were not securely on the foot pedals. These deficiencies were confirmed through staff interviews and observations, highlighting a failure to adhere to safety protocols.
A facility failed to obtain a physician's order for a CPAP machine for a resident with sleep apnea. The resident's CPAP mask was not cleaned between uses, as confirmed by observations and staff interviews. The facility's policy required documentation and physician orders for CPAP use, which were not followed.
Incorrect MDS Coding for Plavix
Penalty
Summary
The facility failed to accurately complete the MDS for four residents by coding Plavix as an anticoagulant medication during the assessment look-back period. For R3, the EMR showed an MDS dated [DATE] that documented receipt of an anticoagulant, while the Orders tab listed Plavix 75 mg by mouth daily for a diagnosis of atherosclerosis arteries of extremities, ordered 01/19/19. For R14, the EMR showed an MDS dated [DATE] that recorded receipt of an anticoagulant, while the Orders tab listed Plavix 75 mg by mouth daily for a diagnosis of cerebral infarction, ordered 11/24/22. For R30, the EMR showed an MDS dated [DATE] that recorded receipt of an anticoagulant, while the Orders tab listed Plavix 75 mg by mouth daily for a diagnosis of atherosclerotic heart disease, ordered 04/24/25. For R2, the admission MDS dated [DATE] recorded receipt of an anticoagulant during the look-back period, while the Orders tab listed Plavix 75 mg by mouth daily for a diagnosis of atherosclerosis arteries of extremities, ordered 12/28/2025. During interview on 05/21/26, the LRN/MDS confirmed the MDS was coded incorrectly regarding Plavix and confirmed Plavix was not an anticoagulant. The Administrative Nurse stated it was the expectation that MDSs be completed accurately.
Failure to Assist Resident With Oral Hygiene
Penalty
Summary
The facility failed to ensure Resident 7 received assistance with activities of daily living, specifically cleansing off her face and lips. Resident 7 had diagnoses of dementia and weakness, a BIMS score of 4 indicating severe cognitive impairment, and care documentation showing she required moderate assistance with personal hygiene and was dependent on staff for personal hygiene. The facility’s ADL policy stated that residents unable to carry out ADLs would receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Observation, record review, and staff interviews showed a dried brown film on Resident 7’s lower lip on multiple occasions while she was seated in common areas and dining areas. On one occasion, she tried to wipe the film off with a tissue and it did not come off. A CNA reported he had been told not to touch her mouth or lips because the brown film was dried blood. An LN stated CNAs should wipe off the resident’s lips and nurses should ensure they did so, while an administrative nurse stated she expected staff to assist the resident with wiping off her lip and was unsure why the resident was on Valtrex for a sore in her mouth.
Failure to Implement Resident-Centered Fall Interventions
Penalty
Summary
The facility failed to identify and implement resident-centered fall interventions for three residents who were at risk for falls. R7 had diagnoses of dementia and unsteadiness on feet, a BIMS score of 4 indicating severe cognitive impairment, and multiple fall assessments showing high fall risk. Her record documented repeated falls, including falls from a recliner, falls while trying to get up without assistance, and a fall that resulted in an intra-thalamic bleed and rib fractures. Her care plan included interventions such as call light use, toileting every two hours, close observation in common areas, 30-minute checks when seated in the living room, and later reminders related to the recliner remote and staff assistance, but the record also showed that she continued to fall and that some interventions were not consistently reflected in the EMR or device assessments after recliner-related falls. R2 had vascular dementia, weakness, unsteadiness on feet, a BIMS score of 7 indicating severely impaired cognition, and was assessed as high risk for falls. He required maximal assistance with transfers and was non-ambulatory. His care plan included close observation related to wandering and poor sleep habits, one-on-one observation overnight when awake, and assistance with toileting. Despite this, R2 fell from a recliner after scooting to the end of the footrest, fell again while in a recliner when staff walked past, and was later observed being transported in a wheelchair without foot pedals while his feet struck the floor during propulsion. Staff interviews showed differing understanding of whether foot pedals should be used and whether one-on-one observation was documented in the EMR. R13 had dementia, a BIMS score of 4 on one assessment and 3 on another, and required staff assistance with standing and mobility using a walker and wheelchair. Her fall history included prior falls with injury and multiple fall assessments that placed her at high risk, although one later assessment placed her at low risk. After an unwitnessed fall, the facility documented interventions such as hourly rounds and a bedside sign reminding her to call for assistance before getting up. However, observations showed her call light on the floor and the bedside table without the reminder sign, and staff interviews indicated they were unaware of her fall interventions. The facility policy stated that appropriate and immediate interventions were to be implemented to prevent reoccurrences and improve resident care.
Missed Breakfast Meals and Weight Loss
Penalty
Summary
The facility failed to ensure Resident 2 received the necessary nutritional support when staff did not provide a breakfast meal for several days in May 2026. Resident 2 had diagnoses of vascular dementia and dysphagia, a BIMS score of 7 indicating severely impaired cognition, and required touching assistance for eating. His care plan and nutritional assessments documented that staff were to supervise or assist with meals, monitor intake and weight, and report significant weight loss. He was on a mechanical soft diet with thin liquids and double protein at meals for wound healing. Record review showed Resident 2’s weight declined from 137.5 pounds on 04/11/26 to 126.6 pounds on 05/13/26. The RD noted an unplanned 7-pound loss in one week on 05/04/26 and later documented a significant unplanned 8% and 7.5% weight loss in one and three months on 05/19/26. The RD also noted that Resident 2 was sleeping more and not eating as well, discontinued the double portion entree, and started an 8-ounce house supplement at bedtime. The facility’s meal intake documentation showed multiple breakfasts with no percentage recorded, several breakfasts marked unavailable, and some marked refused. During observation on 05/20/26 and 05/21/26, Resident 2 was repeatedly found asleep in a recliner in the TV lounge with dry dentures and was not observed receiving breakfast. On 05/20/26, staff reported he had just woken up and did not have breakfast, and no breakfast was observed given to him. On 05/21/26, staff reported he sometimes stayed up late and that family requested he not be awakened for meals; however, the charted progress notes before 05/19/26 could not be located by administrative staff. Staff also acknowledged that he should have been offered something to eat when awakened, and a nurse stated he should have been given breakfast. The facility policy stated each resident would receive at least three meals daily without extensive time lapses between meals.
Medication Error: Insulin Given to Non-Diabetic Resident
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when an LPN administered 30 units of Lantus insulin to a resident who was not diabetic. The resident’s EMR documented dementia, and her MDS assessments documented severe cognitive impairment with BIMS scores of four and three. Her records also showed no diagnosis of diabetes mellitus and no insulin use during the seven-day lookback periods. Her care plan instructed staff to administer medications as ordered. The EMR progress note documented that the LPN gave the insulin into the resident’s left upper arm and immediately realized it had been given to the wrong resident. The LPN notified the on-call physician, and the resident’s blood sugar was monitored throughout the night. The on-call physician ordered hourly blood sugar checks for four hours, then every two hours if stable, with Glucagon and transfer to the emergency room if the blood sugar dropped below 70 mg/dL. The resident’s blood sugar remained stable, with the lowest reading at 115 mg/dL, and the facility continued monitoring until the physician said the resident was stable and checks could stop. The LPN later stated she had administered the insulin to the wrong resident and monitored the resident overnight, and Administrative Nurse C stated staff were expected to administer medications as ordered.
Failure to Provide Ordered Nectar-Thick Liquids
Penalty
Summary
The facility failed to ensure a cognitively impaired resident with dementia and severe cognitive impairment received liquids in the prescribed nectar-thick consistency. The resident’s physician orders documented a regular mechanical soft diet with nectar consistency liquids, but the care plan lacked documentation of the nectar-thick liquid order. The dietary note stated nursing reported the resident was having trouble swallowing liquids and wanted slightly thickened liquids, and the facility noted that PointClickCare only had nectar thick liquids available as a diet option. During dining room observations, the resident was seen with regular thin liquids in front of her, including apple juice, orange juice, and water. On one occasion, the resident drank a full glass of orange juice and about 100 ml of apple juice before a CNA confirmed the juices were not nectar thick and stated she did not know who gave them to the resident. On another occasion, a CMA observed regular thin water in front of the resident and pushed it away, while dietary staff stated the resident was on nectar thick liquids and that the correct fluids should have been passed. Staff also reported the resident usually liked coffee and that her coffee was nectar thick when prepared by staff.
Infection Control Lapses During Resident Care and Linen Transport
Penalty
Summary
The facility failed to utilize Enhanced Barrier Precautions during direct care for a resident with open wounds to both knees. During assistance to the bathroom and transfer to the toilet, two CNAs applied gloves but did not perform hand hygiene or use other PPE before providing hands-on care, including removing a soiled brief, cleansing the resident, pulling up clothing, and assisting the resident back to a wheelchair. One CNA also removed gloves without hand hygiene and handled the resident’s shoes and gait belt during the encounter. Both CNAs later stated they did not know the resident was on EBP, although they confirmed the EBP door sticker was present and acknowledged that hand hygiene should have been performed. A nurse also failed to maintain hand hygiene during a dressing change for the same resident. The nurse entered the room with hand hygiene, gloves, and a gown, removed the dressing from one knee, cleansed both open knee areas, then removed gloves and attempted to obtain another pair without performing hand hygiene before continuing the dressing change. The nurse later stated she did not think to perform hand hygiene when she removed her gloves before applying new ones and acknowledged the resident was on EBP and that staff should wear PPE for hands-on care. The facility also failed to ensure adequate hand hygiene and linen handling during other resident care activities. Two CNAs providing perineal care for another resident entered the room with gloves and gowns, but one CNA used gloved hands to open drawers, cupboards, and closet doors while looking for supplies, and both removed and reapplied gloves without hand hygiene during care. A laundry staff member delivered personal clothes on an uncovered linen cart and hugged the clothes against her uniform while moving them down the hallway. Additional observations showed a nurse handling items from the floor and entering a room without hand hygiene before administering insulin, and another nurse carrying gloves, alcohol prep, and an insulin pen in a pocket before moving a resident and then administering insulin without hand hygiene.
COVID-19 Vaccine Offer and Documentation Deficiencies
Penalty
Summary
The facility failed to offer and provide, or obtain an informed declination for, the COVID-19 vaccine for a resident. Resident 2's electronic medical record lacked documentation that a COVID-19 vaccine had been offered since 2022. The facility also failed to maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status. During interview, the Administrative Nurse responsible for infection prevention stated that the facility does not maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status, and that ill staff are told to go to their provider and notify the facility. The facility's Infection Prevention and Control Program, dated 02/15/26, stated that residents and staff will be offered the COVID-19 vaccine when supplies are available and that the facility will maintain documentation showing staff were educated about the benefits and potential risks of the vaccine and were offered the vaccine or information on how to obtain it.
Inaccurate Reporting of Licensed Nurse Coverage
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility did not accurately report 24-hour per day Licensed Nurse (LN) coverage on several dates between April 1, 2023, and June 30, 2023, as well as between October 1, 2023, and December 31, 2023. The Payroll Base Journal (PBJ) Staffing Data Report for the third quarter of fiscal year 2023 revealed that the facility lacked LN coverage for 24 hours on specific dates in May and June. Similarly, the PBJ for the first quarter of fiscal year 2024 showed missing LN coverage on certain dates in November and December. An interview with Administrative Staff A on August 12, 2024, indicated that the information regarding licensed nurse hours might not have been submitted accurately to reflect the actual hours worked by licensed nurses. The facility's policy, dated January 1, 2024, instructed staff to submit complete and accurate staffing information, including agency and contract staff, based on payroll and other verifiable data in a uniform format according to CMS specifications. Despite this policy, the facility failed to meet the requirements, resulting in inaccurate reporting of LN coverage.
Failure to Complete Comprehensive Assessments and Care Plans
Penalty
Summary
The facility failed to complete comprehensive assessments and develop care plans for four residents, as required by the Minimum Data Set (MDS) and Care Area Assessments (CAA). For Resident 31, the facility did not develop CAAs for areas triggered by the MDS, including Cognitive Loss/Dementia, Mood State, Psychotropic Drug Use, and Behavioral Symptoms. This resident had severe cognitive impairment and was on multiple medications, including antipsychotics and opioids, but did not receive scheduled pain medications, only as needed. The lack of a comprehensive assessment could lead to uncommunicated care needs. Resident 8's medical record showed diagnoses of neurogenic bladder dysfunction and hemiplegia, with an indwelling urinary catheter and a desire to return home. The facility did not develop CAAs for Urinary Incontinence, Indwelling Catheter, ADL Functional/Rehabilitation Potential, Pain, and Return to Community. Despite having normal cognitive function, the resident's care needs were not fully assessed, potentially leading to uncommunicated needs. For Resident 15, who had severe cognitive impairment and required substantial assistance for transfers, the facility failed to analyze findings for triggered CAAs, including Delirium, Cognitive Loss/Dementia, Psychotropic Drug Use, and Pain. Similarly, Resident 4, with severe cognitive impairment and requiring maximal assistance, had CAAs that lacked analysis for multiple areas, including Delirium and Falls. The facility's failure to complete these assessments accurately could result in uncommunicated needs for these dependent residents.
Failure to Include CPAP in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with sleep apnea who utilized a Continuous Positive Airway Pressure (CPAP) machine. The resident's electronic medical record did not include a physician's order or indication for the CPAP, and the care plan lacked staff instructions on the use and care of the CPAP. Observations revealed that the CPAP mask was not being cleaned between uses, as evidenced by a dried white substance on the mask, which the resident confirmed was not being cleaned by the staff. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognition, reported using the CPAP every night. Despite this, the facility's care plan did not address the resident's use of the CPAP machine, contrary to the facility's policy requiring comprehensive person-centered care plans. An administrative nurse acknowledged the expectation for the CPAP to be included in the care plan, highlighting the oversight in meeting the resident's medical and nursing needs.
Improper Wheelchair Positioning for Resident with Dementia
Penalty
Summary
The facility failed to ensure appropriate positioning for a resident with severe cognitive impairment, who was dependent on staff for mobility in a specialized wheelchair. The resident's electronic medical record indicated a diagnosis of dementia, and assessments showed severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of five. The care plan and records from mid-July to mid-August documented the resident's dependence on staff for mobilization in her wheelchair. However, observations on two separate occasions revealed that the resident's feet were dangling approximately eight inches above the footrest of her wheelchair, indicating improper positioning. Interviews with staff members, including a CNA and a licensed nurse, confirmed that the resident's feet did not always reach the footrest, and it was acknowledged that the feet should rest comfortably on the footrest. The facility's policy on the use of assistive devices, implemented in April 2023, required direct care staff to be trained on the use of such devices to ensure safe and comfortable positioning for residents. Despite this policy, the facility did not ensure that the resident was positioned properly in her wheelchair, leading to the identified deficiency.
Deficiencies in Safe Transfers and Wheelchair Transport
Penalty
Summary
The facility failed to provide safe transfers for two residents, R4 and R15, who both had severe cognitive impairments and required substantial to maximal assistance for transfers. R15's care plan indicated the need for substantial assistance of two staff members and the use of non-skid footwear during transfers. However, during a transfer from a specialized wheelchair to a bed, R15 was not wearing non-skid footwear, was unable to bear weight, and her legs became twisted as her feet slid on the floor. Similarly, R4 required substantial assistance and non-skid footwear, but during a transfer, the resident was not wearing non-skid footwear, was unable to bear weight, and the staff failed to use a gait belt, resulting in the resident's feet sliding on the floor. The facility also failed to provide safe wheelchair transport for R28, who had severe cognitive impairment and required staff assistance for wheelchair mobility. The care plan instructed staff to remove foot pedals when not propelling the resident. However, during transport, the resident's feet were not securely on the foot pedals, with one foot pulled back underneath the wheelchair and the other skimming the floor. Staff confirmed the resident was unable to keep her feet on the foot pedals due to their position. The facility's policies for safe resident transfers and the use of assistive devices were not followed, as evidenced by the lack of non-skid footwear, failure to use mechanical lifts for non-weight-bearing residents, and improper use of wheelchair foot pedals. These deficiencies were confirmed by staff interviews and observations, indicating a failure to adhere to established safety protocols for resident transfers and mobility assistance.
Failure to Obtain Physician's Order and Maintain CPAP Equipment
Penalty
Summary
The facility failed to obtain a physician's order for the use of a Continuous Positive Airway Pressure (CPAP) machine for a resident diagnosed with sleep apnea. The resident's electronic medical record did not include a physician's order or indication for the CPAP, despite the resident stating that she used the CPAP every night. Observations revealed that the CPAP mask was not being cleaned between uses, as it was found with a dried white substance on multiple occasions. The resident expressed concerns that the staff were not cleaning her mask, and Certified Nurse Aides confirmed that the resident was responsible for the care of her CPAP mask. The facility's policy for Noninvasive Ventilation required documentation of CPAP use, resident tolerance, and any changes as ordered by a physician. However, the facility did not adhere to this policy, as confirmed by an Administrative Nurse who acknowledged the lack of a physician's order for the CPAP machine. This oversight in obtaining a necessary physician's order and ensuring proper maintenance of the CPAP equipment represents a deficiency in providing safe and appropriate respiratory care for the resident.
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 2 citations issued within 25 miles in the last 12 months — 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 Garnett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anderson County Hospital Ltcu | 0.7 mi | ★★★★★ | 0 | 0 |
| Richmond Healthcare & Rehab Center | 7.9 mi | ★★★★★ | 1 | 0 |
| Rock Creek Of Ottawa | 21.5 mi | ★★★★★ | 1 | 0 |
| Moran Manor | 25.3 mi | ★★★★★ | 0 | 0 |
| Medicalodges Iola | 25.7 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Parkview Heights Nursing And Rehabilitation Center.
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.