Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Parkway Operator Llc during CMS and state inspections, most recent first.
The facility failed to submit complete and accurate staffing information through PBJ, as required by CMS. The PBJ report indicated a lack of 24/7 licensed nurse coverage on multiple dates, despite timeclock data showing otherwise. Administrative Staff B noted that discrepancies might arise from manually entered agency staffing hours. The facility did not provide a PBJ reporting policy upon request.
A facility failed to maintain a medication error rate below five percent when a nurse administered medications via a G-tube without a physician's order. The resident's MAR lacked specific instructions for mixing and administering medications through the G-tube, and the nurse did not flush the tube before or after administration. Interviews revealed that the facility's policy allowed for mixing medications unless contraindicated, but the MAR should have included specific orders and flushing instructions. The facility could not provide a policy for Medication Administration or Medication Errors, leading to a 23.08% medication error rate.
The facility failed to implement proper signage for Enhanced Barrier Precautions (EBP) in rooms of residents requiring such precautions. Observations revealed that rooms with residents having tracheostomies, PEG tubes, Foley catheters, and fistulas lacked visible indicators, despite having PPE storage bins. Staff confirmed that EBP information was communicated verbally or through electronic records, but not visibly posted, contrary to the facility's policy. This oversight placed residents at risk for infectious diseases.
A resident was transferred to a hospital without receiving written notification specifying the location and reason for the transfer. The facility typically informed family members via phone calls rather than written notifications, as confirmed by staff interviews. The resident's EMR lacked documentation of the written notification, and the facility did not provide a policy related to written notification and bed hold for discharges and transfers.
A resident was transferred to a hospital without receiving a written notification of the bed hold policy from the facility. Despite the resident's intact cognition and multiple medical conditions, the facility assumed the resident would return and did not issue the required notice. Interviews with staff confirmed the oversight, and the facility lacked a documented policy for such notifications.
A resident with respiratory failure, UTI, and COPD had a care plan that failed to address his functional abilities and Foley catheter care. The care plan was not updated after a hospital visit, leading to a lack of staff direction for ADLs and catheter care, placing the resident at risk of impaired care.
The facility failed to update care plans for two residents, one with bowel incontinence and another at risk for pressure ulcers. The first resident's care plan lacked interventions for bowel incontinence, despite assessments indicating the need. The second resident's care plan did not include pressure-reducing measures, even though the resident had a history of skin issues and was at risk for pressure ulcers. Staff interviews and observations confirmed these deficiencies.
A resident with severe cognitive impairment and multiple medical conditions was at risk for pressure ulcers due to improper settings on a low air-loss mattress. The resident's care plan included pressure-reducing devices, but it lacked specific instructions for the mattress weight setting. Observations showed incorrect settings, and staff interviews revealed confusion about responsibility for adjustments, placing the resident at risk for skin breakdown.
Incomplete PBJ Staffing Information Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required by the Centers for Medicare & Medicaid Services (CMS). The PBJ report for Fiscal Year 2023 Quarter 3, FY 2024 Quarter 1, and FY 2024 Quarter 2 indicated that the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple dates. However, a review of the facility's licensed nurse timeclock data for those dates showed that a licensed nurse was on duty 24 hours a day, seven days a week. An observation on 08/07/24 confirmed a licensed nurse was on duty. Administrative Staff B explained that they verify hours through their clock-in system and upload the hours to the PBJ, with corporate sending the final report. They noted that agency staffing hours were entered manually based on invoice information, which could lead to discrepancies. The facility did not provide a policy related to PBJ reporting upon request, contributing to the deficiency.
Medication Error Due to Lack of Physician's Order for G-tube Administration
Penalty
Summary
The facility failed to ensure the medication error rate did not exceed five percent when a licensed nurse administered medications to a resident via a gastrostomy tube (G-tube) without a physician's order. The resident's Medication Administration Record (MAR) indicated an order to crush medications as appropriate, but there was no specific order to mix and administer them via G-tube. The nurse crushed six medications, including citalopram hydrobromide, prednisone, a probiotic, vitamin D3, senna, and sotalol, and administered them through the G-tube without flushing the tube before or after the administration. Interviews with staff revealed that the facility's policy allowed for mixing enteral medications unless contraindicated, but the resident's MAR should have included an order for mixing medications and instructions for flushing the G-tube. The administrative nurse confirmed that each resident receiving medications via G-tube should have a physician's order for mixed administration and specified flushing instructions. The facility was unable to provide a policy for Medication Administration or Medication Errors, resulting in a medication error rate of 23.08%.
Failure to Implement Signage for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper signage or indicators for Enhanced Barrier Precautions (EBP) in rooms of residents who required such precautions. During an initial walkthrough, it was observed that several residents' rooms, including those with tracheostomies, PEG tubes, Foley catheters, and fistulas, had over-the-door storage bins containing personal protective equipment (PPE) but lacked any signage or indicators to alert staff and visitors of the necessary precautions. This oversight was confirmed through interviews with staff, who indicated that information about EBP was communicated verbally or through electronic medical records, but not visibly posted in or outside the rooms. The facility's policy on Enhanced Barrier Precautions, revised in March 2024, stated that high-contact care signage should be utilized for residents on EBP. However, the policy was not followed, as evidenced by the absence of such signage in the rooms of nine residents identified as being on EBP. This lack of visible indicators placed residents at risk for infectious diseases, as staff, visitors, and outside vendors were not adequately informed of the necessary precautions upon entering these rooms.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written notification of transfer to a resident, identified as R43, and/or their representative, specifying the location and reason for the facility-initiated transfer. R43 was admitted to the facility and later discharged to a hospital due to right lower quarter abdominal pain experienced during a therapy session. The resident's Electronic Medical Records (EMR) included diagnoses of acute kidney failure, COPD, chronic respiratory failure, heart failure, muscle weakness, and type two diabetes mellitus. Despite the resident's intact cognition, as indicated by a BIMS score of 15, the EMR lacked documentation showing that written notification of the transfer was provided to the resident or their representative. Interviews with facility staff revealed that the facility typically informed family members of transfers via phone calls rather than providing written notifications. Social Service Staff X and Administrative Nurse D both confirmed that written notifications were not issued because the facility believed the resident was returning. Additionally, the facility did not provide a policy related to written notification and bed hold for discharges and transfers when requested. This oversight placed the resident at risk for miscommunication and potential missed opportunities for healthcare services.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a written notification of the bed hold policy to a resident, identified as R43, or their representative at the time of the resident's transfer to a hospital. R43 was admitted to the facility and later discharged to the hospital due to acute medical conditions, including acute kidney failure, COPD, chronic respiratory failure, heart failure, muscle weakness, and type two diabetes mellitus. Despite having intact cognition as indicated by a BIMS score of 15, there was no documentation in R43's electronic medical records showing that a bed hold policy was communicated to him or his representative. The deficiency was further highlighted during interviews with facility staff. Social Service Staff X and Administrative Nurse D both acknowledged that a written notification was not issued because the facility assumed R43 would return. The facility's failure to provide a bed hold policy notice posed a risk to R43's ability to return to the facility and to his previous room. Additionally, the facility did not provide a policy related to written notification and bed hold for discharges and transfers when requested.
Deficiency in Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan addressed his functional abilities and the level of assistance required from staff. The resident, who had diagnoses of respiratory failure, urinary tract infection, and chronic obstructive pulmonary disease, was noted to have moderately impaired cognition and required varying levels of assistance with activities of daily living (ADLs). Despite these needs, the care plan lacked specific interventions for ADL assistance and Foley catheter care, which are critical for the resident's well-being. The deficiency was identified when it was observed that the resident's care plan had not been updated to reflect his current needs after a hospital visit. Both a licensed nurse and an administrative nurse acknowledged that the care plan had been overlooked and not revised to include necessary interventions for ADLs and catheter care. This oversight placed the resident at risk of impaired care due to uncommunicated care needs, as the care plan did not provide staff with adequate direction for his care.
Care Plan Deficiencies for Incontinence and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to revise the care plan for a resident with bowel incontinence needs, which placed the resident at risk for complications. The resident had multiple medical diagnoses, including congestive heart failure, type two diabetes mellitus, and spinal stenosis, and was frequently incontinent of bowel and bladder. Despite assessments indicating the need for assistance with toileting and the risk for skin breakdown and urinary tract infections, the care plan did not include interventions for bowel incontinence or the use of disposable incontinence products. Observations and staff interviews confirmed the lack of detailed interventions in the care plan. Another resident's care plan was not updated to include preventative measures for pressure ulcers on the heels and ankles, despite being at risk for skin breakdown due to impaired mobility and a history of skin issues. The resident had a pressure wound on the right knee and redness on the right inner ankle. Observations showed the resident's positioning in bed, and staff interviews revealed attempts to use pressure-reducing measures, such as pillows and wedges, which the resident sometimes resisted. The care plan lacked documentation of these interventions and the resident's refusals. The facility's care plan policy required comprehensive assessments and individualized interventions to reflect treatment needs, with updates to reflect changes in residents' goals and care needs. However, the facility did not revise the care plans for these residents, leading to uncommunicated care needs and increased risks for complications.
Improper Mattress Setting for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident's low air-loss mattress pump was set to the appropriate weight range, which is crucial for preventing pressure ulcers. The resident, who had severe cognitive impairment and was dependent on staff for mobility and other daily activities, was at risk for pressure ulcers due to his medical conditions, including type two diabetes mellitus, cerebral infarction, and neuromuscular bladder dysfunction. Despite having no active pressure injuries, the resident's care plan included the use of pressure-reducing devices and a repositioning program. However, the care plan did not specify the correct weight setting for the low air-loss mattress or the monitoring requirements. Observations revealed that the mattress was set incorrectly on two occasions, first at 300 lbs and then at 180 lbs, while the resident's weight was documented as 155 lbs. Interviews with staff indicated a lack of clarity and responsibility regarding the adjustment of the mattress settings. A licensed nurse mentioned that the mattress should be set based on the resident's weight, but the administrative nurse stated that an outside company installed the mattresses and set the weight settings, and staff did not adjust them. This lack of proper setting and monitoring of the mattress placed the resident at risk for complications related to skin breakdown and pressure ulcers.
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What surveyors actually found near you
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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 Edwardsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kaw River Care And Rehab | 0 mi | ★★★★★ | 0 | 0 |
| Edwardsville Care And Rehab | 0 mi | ★★★★★ | 2 | 2 |
| Bonner Springs Nursing & Rehab Center | 3.4 mi | ★★★★★ | 0 | 0 |
| Brookdale Rosehill | 5 mi | ★★★★★ | 15 | 0 |
| The Healthcare Resort Of Kansas City | 5.2 mi | ★★★★★ | 32 | 0 |
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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.