Above average — CMS composite of the measures below.
The next survey window likely opens around May 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 Parsons Presbyterian Manor during CMS and state inspections, most recent first.
PRN lorazepam orders for two residents with anxiety lacked required stop dates. One resident had intact cognition and documented antianxiety medication use, while the other had documented psychotropic use and impaired cognition; both had care plans to monitor for side effects, and an RN confirmed the orders did not include the stop date required by facility policy for PRN psychotropic meds.
Failure to provide written transfer notice and ombudsman notification. A resident with a femur fracture and CVA, who had intact cognition, had an unplanned discharge after the family requested the resident's meds and laundry be ready. The EMR lacked documentation of a written transfer/discharge notice to the resident or rep and lacked proof that the ombudsman was notified; an admin staff member could not locate either document and said another staff member was supposed to handle the ombudsman notifications but did not.
A resident with vascular dementia, self-care deficit, and MDD was dependent on staff for bathing and personal hygiene, yet the facility did not document or provide shaving assistance as part of routine grooming. Staff observed chin hair on the resident, and both the CNA and an administrative nurse confirmed shaving should be offered when needed and during bathing, but there was no evidence the resident had been offered help with shaving and the facility lacked a policy addressing shaving as part of ADL care.
Failure to provide restorative ROM care for a resident with hemiparesis/hemiplegia and a left-hand contracture. The resident’s care plan directed daily PROM to the left upper extremity, but the EMR lacked documentation of PROM, and observations showed the left hand curled into a fist. CNAs and administrative nurses confirmed the resident was not receiving the planned restorative nursing care.
A significant medication error occurred when a fatigued CMA administered another resident's medications to a cognitively impaired resident, leading to life-threatening hypotension. The resident, who had a history of hypertension, experienced a rapid drop in blood pressure and required emergency transport to the ED. The error was realized after administration, and the CMA continued to pass medications despite her fatigue.
The facility failed to properly maintain and dispose of garbage, leading to unsanitary conditions with open dumpster compartments and surrounding discarded building supplies. Staff confirmed the need to keep dumpster lids closed to prevent pest attraction, but the facility lacked a policy for proper garbage disposal.
The facility failed to submit accurate staffing data to CMS, missing 24-hour LN coverage on multiple dates across two fiscal quarters. Despite believing submissions were correct, discrepancies were found in the PBJ Staffing Data Report, revealing gaps in LN coverage.
A resident with multiple health conditions was verbally abused by a CNA, who called the resident 'lazy' in front of others. The incident was witnessed by two staff members but was not reported to management until nine days later, violating the facility's policy on prompt reporting of abuse.
A resident with severe cognitive impairment experienced a skin tear on his hand, but the facility failed to investigate the cause or implement immediate interventions to prevent further injury. Despite the resident's known risk for skin tears and need for assistance, the facility lacked a policy for root cause analysis, and staff did not document preventive measures after the incident.
A resident with a stage two sacral pressure ulcer was found to be using a malfunctioning pressure-relieving cushion in their recliner. Despite having a care plan that included a low air loss mattress and specific wound care instructions, the cushion was deflated and not reported by staff, leading to inadequate pressure reduction. The facility failed to monitor the cushion's status, as required by their policy on therapeutic support surfaces.
A resident with severe cognitive impairment and fall risk was transferred using a sit to stand lift with a broken safety belt, which had been in disrepair for over a week. Staff failed to report the issue, violating facility policy on equipment maintenance and resident safety.
PRN Lorazepam Orders Lacked Required Stop Dates
Penalty
Summary
The facility failed to obtain a stop date for PRN lorazepam orders for two residents. One resident had a diagnosis of anxiety, intact cognition with a BIMS score of 14, and documentation in the EMR showing use of antianxiety medication during the assessment period. Her psychotropic drug use CAA and care plan both reflected anxiety and monitoring for side effects of antianxiety medication, but the physician order for lorazepam 0.5 mg by mouth every four hours PRN for anxiety, ordered 04/08/2026, did not include a stop date. Administrative Nurse D confirmed on 06/03/2026 that the PRN lorazepam order lacked the required stop date. The second resident also had a diagnosis of anxiety and psychotropic medication use documented in the EMR and CAA. Her MDS assessments showed varying cognitive impairment, including a BIMS score of 6 on one assessment and 11 on another, and her care plan instructed staff to monitor for side effects of antianxiety medication. The EMR order for lorazepam 0.5 mg by mouth every four hours PRN for anxiety, ordered 10/19/2025, also lacked a stop date. Administrative Nurse D confirmed on 06/03/2026 that this PRN lorazepam order did not have the required stop date, consistent with the facility policy limiting PRN psychotropic medications to no more than 14 days unless extended with documented rationale and a specific duration.
Failure to Provide Written Transfer Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide Resident 31 with a written notification of transfer or discharge to the resident and/or the resident's representative as soon as practicable, and failed to send a copy of that notification to the ombudsman. Resident 31 had diagnoses of left femur fracture and CVA, and the admission MDS documented a BIMS of 15, indicating intact cognition. The discharge MDS documented an unplanned discharge, and nursing notes showed the resident's daughter requested the resident's medications and laundry be ready for discharge, followed by a note that the family took the resident home with medications and belongings. The resident's EMR did not contain documentation of a written transfer notification explaining the reason for the transfer to the hospital or documentation that the ombudsman was notified. During interview, Administrative Staff A could not locate the letter to the family or the ombudsman notification for the discharge, and stated another staff member was supposed to handle ombudsman notifications for March and April but did not do so.
Failure to Provide Shaving Assistance as Part of ADL Grooming
Penalty
Summary
The facility failed to provide grooming opportunities related to shaving facial hair to maintain good personal hygiene and dignity for a resident with vascular dementia, self-care deficit, and major depressive disorder. The resident’s records showed moderate cognitive impairment, dependence on staff for bathing and personal hygiene, and a care plan that directed staff to explain procedures, assist with ADLs as needed, and provide bathing and grooming support, including restorative nursing involvement for dressing and grooming. Review of EMR bathing tasks and bath sheets from 05/01/2026 through 06/02/2026 showed no evidence that staff offered or provided shaving during scheduled bath or shower days or as needed. During observation, the resident was seen with approximately one-quarter inch of chin hair and stated she wanted staff help removing it and asked whether it was visible. A CNA later confirmed the resident needed shaving and stated residents should be offered shaving assistance as part of bathing and grooming. An administrative nurse also confirmed that when residents were observed with chin hair, staff should offer to shave them when needed and when bathed, and verified there was no evidence the resident had been offered assistance with shaving. The administrative nurse reported the facility lacked a policy addressing shaving as part of ADL care.
Failure to Provide Restorative ROM Care for Resident with Left-Hand Contracture
Penalty
Summary
The facility failed to provide restorative care to a resident with hemiparesis/hemiplegia and limited range of motion, including a contracture of the left hand. The resident’s EMR documented a diagnosis of hemiparesis/hemiplegia, and MDS assessments showed moderately impaired cognition with limited ROM on one side of the upper and lower extremities. The care plan revised 04/14/2026 directed staff to provide passive ROM restorative care to the resident’s left upper extremity daily, including opening and closing the left hand, elbow extension, and shoulder raises for 15 minutes up to seven days per week. The resident’s EMR from 05/04/2026 through 06/01/2026 lacked documentation that PROM was provided. During observation on 06/01/2026, the resident was feeding herself with her right hand while her left hand rested in her lap with fingers curled inward into a fist. On 06/03/2026, CNAs transferred the resident with a full body lift and the left hand remained curled into a fist. CNA O stated she would open the resident’s left hand enough to clean her fingers and palm but the resident was not able to fully open the hand and move her fingers. CNA O was unsure whether restorative care was being provided, CNA M stated the resident did not receive restorative care, and Administrative Nurses E and D confirmed the resident had not been receiving the planned restorative nursing cares for the left-hand contracture.
Significant Medication Error Due to Fatigue
Penalty
Summary
The facility failed to prevent a significant medication error involving a cognitively impaired resident, R1, when Certified Medication Aide (CMA) R administered another resident's medications to R1. On the evening of 09/12/24, CMA R, who was reportedly fatigued, mistakenly gave R2's medications, Crestor 20 mg and Coreg 25 mg, to R1, along with R1's scheduled mirtazapine 15 mg. This error occurred during the supper meal when R1 and R2 were seated together at the dining table. CMA R realized the mistake after administering the medications and immediately checked R1's vital signs, which were stable at that time. R1, who had a history of hypertension and severely impaired cognition, experienced a significant drop in blood pressure following the medication error. Initially, R1's blood pressure was recorded at 158/74 mmHg, but it decreased to 82/45 mmHg and then to 75/37 mmHg within a short period. The resident exhibited symptoms of life-threatening hypotension, including tremors and unresponsiveness, prompting the nursing staff to call EMS for emergency transport to the Emergency Department (ED). Interviews with staff revealed that CMA R was fatigued during her shift and had to splash water on her face to stay alert. Despite this, she continued to pass medications until the end of her shift. The facility's administrative and nursing staff were unaware of CMA R's fatigue until after the incident. The error was reported to R1's healthcare provider, who advised monitoring R1's vital signs every two hours. However, due to the rapid decline in R1's condition, emergency medical intervention was required.
Removal Plan
- the facility suspended CMA R.
- Licensed Nurses (LN) and Certified Medication Aides (CMA) were provided education related to Medication Administration.
- Licensed Nurse (LN) and Certified Medication Aides (CMA) completed a Medication Administration check-off observed by Administrative Nurse A.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to maintain and dispose of garbage and refuse properly, leading to unsanitary conditions that could attract pests. During an initial tour, it was observed that two out of four compartments of the dumpster were open, exposing trash and garbage. Additionally, discarded building supplies were found surrounding the dumpster, with grass growing over the edges. Dietary Staff BB confirmed these findings and stated that the facility staff should keep all dumpster lids closed to prevent pest harborage. On a subsequent environmental tour, it was noted that the dumpster lacked one lid, further exposing trash and garbage. The Housekeeping and Maintenance Director U and Consultant GG acknowledged the issue, noting that the trash company had replaced the dumpster approximately two weeks prior. The facility did not have a policy in place to address the proper disposal and containment of garbage and refuse.
Inaccurate Staffing Data Submission to CMS
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 12 dates between July 1, 2023, and September 30, 2023, and on 10 dates between January 1, 2024, and March 31, 2024. The Payroll Base Journal (PBJ) Staffing Data Report for these periods revealed gaps in LN coverage for 24 hours a day, seven days a week, on specified dates. This discrepancy was identified during a review of the PBJ Staffing Data Report for the fiscal year quarters in question. An interview with Administrative Staff A indicated that, to their knowledge, the PBJ was submitted correctly, and they believed that the licensed nurses working on weekends did not leave the facility or take lunch breaks, thus ensuring 24-hour coverage. However, the facility's policy for PBJ Reporting Procedure, which was undated, required staff to report PBJ hours to CMS quarterly, including data from Time Tracker, an electronic method for recording staff time, and agency staff. Despite these procedures, the facility failed to meet the CMS requirements for accurate staffing data submission.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility staff failed to report an allegation of verbal abuse involving a resident, identified as R4, who was called 'lazy' by a Certified Nurse's Aide (CNA O) in the presence of other residents. This incident occurred in the dining room, where CNA O was observed yelling at R4 and telling him he could push himself to his room. The event was witnessed by Certified Medication Aide (CMA R) and another Certified Nurse's Aide (CNA N), but it was not reported to the facility management until nine days later when CNA N resigned and disclosed the incident. R4, a resident with multiple health conditions including diabetes, heart failure, depression, and morbid obesity, required assistance with activities of daily living and used a wheelchair. Despite being cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, R4 did not recall the incident when interviewed later. The facility's policy mandates that any occurrence or suspected occurrence of neglect or abuse must be promptly reported to management, which did not happen in this case. The failure to report the verbal abuse immediately prevented the facility from taking timely action to protect the residents. The incident was only addressed after the facility was informed, leading to the suspension and eventual termination of CNA O. The delay in reporting the abuse was acknowledged by the facility's administrative staff, who confirmed that the staff did not follow the required protocol for reporting such incidents.
Failure to Investigate and Prevent Skin Tear in Resident
Penalty
Summary
The facility failed to conduct a thorough investigation into the causes and contributing factors of a skin tear experienced by a resident, identified as R18. The resident, who has severe cognitive impairment due to dementia and other health issues, was at risk for skin tears and required substantial assistance for daily activities. Despite these needs, the facility did not identify the cause of the skin tear or implement immediate interventions to prevent further injury. Observations revealed that the resident had a skin tear on the back of his right hand, which was treated with steri-strips and a foam dressing, but there was no documentation of the cause or preventive measures. The facility's lack of a policy for root cause analysis of skin tears contributed to the deficiency. Staff observations noted that the resident would hit his hand against walls and doorways while moving independently, yet no immediate intervention was documented to address this behavior. The administrative nurse confirmed the absence of a thorough investigation and immediate intervention, highlighting a gap in the facility's response to the resident's injury.
Failure to Maintain Pressure-Relieving Device for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a pressure-relieving device was in working order for a resident with a stage two sacral pressure ulcer. The resident, who had a history of diabetes, polyneuropathy, venous ulcers, and a stage two pressure ulcer, was assessed as having normal cognitive function and required partial assistance for transfers. Despite being assessed as not at risk for pressure ulcer development initially, the resident developed a stage two pressure ulcer and was provided with a pressure-reducing device for his chair and bed. The care plan included instructions for using a low air loss mattress and a cushion in the resident's chair, as well as specific wound care instructions. During an observation, it was noted that the resident was seated on two cushions in his recliner, and upon further inspection, it was found that the cushion contained multiple areas of malfunctioning air cells and was deflated. The administrative nurse, who was preparing to change the resident's dressing, was unaware of the deflated cushion until the observation and proceeded to replace it with a foam cushion. The facility's policy on therapeutic support surfaces required staff to consider chair seat cushions for residents in a sitting position, but the facility failed to monitor the status of the resident's cushion to ensure it was functioning optimally to provide pressure reduction.
Failure to Ensure Safe Transfer Due to Broken Equipment
Penalty
Summary
The facility failed to ensure a safe transfer for Resident 18, who has severe cognitive impairment and requires maximum assistance for transfers, by not using the safety belt on a sit to stand lift. The resident, diagnosed with dementia, dizziness, and hypertension, was at risk for falls and required two staff members for transfers. On the day of the incident, staff used a sit to stand lift with a broken safety belt, which had been in disrepair for over a week. Despite the equipment's condition, staff continued to use it without reporting the issue to the maintenance department. The facility's policy mandates that equipment in need of repair should be communicated to the environmental services department, and the safety belt should be used to ensure resident safety during transfers. However, the staff did not report the broken safety belt until the day of the incident, and the lift was used without the necessary safety precautions. This oversight led to a deficiency in providing a safe environment for the resident's care, as the facility did not adhere to its own policies regarding equipment maintenance and resident safety during transfers.
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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 Parsons
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elmhaven East | 2.1 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Parsons | 2.8 mi | ★★★★★ | 0 | 0 |
| Prairie Mission Retirement Village | 13.8 mi | ★★★★★ | 0 | 0 |
| Oswego Operator, Llc | 16.1 mi | ★★★★★ | 14 | 0 |
| Advena Living Of Cherryvale | 16.1 mi | ★★★★★ | 24 | 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.