Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parkview Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident was admitted with bipolar disorder, delusional disorder, and chronic kidney disease and had a Level I PASARR completed on admission. Later, schizophrenia was added as a diagnosis, supported by a physician letter noting a long-standing history of schizophrenia, hallucinations, delusions, and psych evaluations confirming the diagnosis. Despite facility policy requiring a new PASARR when a possible serious mental disorder arises after admission, staff did not initiate a new Level I PASARR at the time the schizophrenia diagnosis was added, and leadership later acknowledged they were unaware that this PASARR had not been completed.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans and to carry out existing interventions for three residents. One resident with paraplegia and a urostomy managed her own drainage by attaching catheter tubing to her pouch and hanging the tubing over a trash can without performing hand hygiene, and her care plan lacked interventions addressing her self-care and hand hygiene despite her cognitive intactness. Another resident with hemiplegia had a physician order and care plan for a left-hand splint to be worn a set number of hours daily, yet repeated observations showed the splint unused by the TV and no documentation of implementation in the record. A third resident with hemiplegia had orders and a care plan for a right resting hand splint and a left palm guard, but observations over several days showed the right splint not in place and sitting on the bedside table, while staff interviews revealed inconsistent awareness and follow-through on splint orders and care plan directives.
The facility failed to implement ordered splinting and restorative ROM interventions for two residents with hemiparesis and limited ROM. One resident with a contracted hand and left-sided weakness had a care plan and physician order for a left hand splint to be worn daily, yet surveyors repeatedly observed the resident without the splint, which was left by the television, and an LPN acknowledged there was no documentation of splint use. Another resident with hemiplegia and seizures had orders and a care plan for a right resting hand splint and left palm protector, along with a restorative program including daily PROM and splint use, but surveyors repeatedly found the right splint off and placed on the bedside table while the left palm protector was in place. Staff interviews revealed inconsistent awareness and implementation of splint orders, frequent reassignment of restorative aides to floor duties, and reliance on CNAs and nurses to apply splints despite clear expectations in the care plans, TAR, and facility policies.
Surveyors found that controlled drugs, including lorazepam oral concentrate and injectable vials, were stored in unlocked or improperly secured conditions in medication refrigerators. An LPN and unit managers reported that they believed the locked medication room and locked refrigerator provided adequate double-lock security and were unaware that refrigerated narcotics required a separate, affixed lock box. Observations showed narcotic lock boxes in the refrigerators were either absent or not permanently affixed, contrary to facility policy requiring controlled substances to be stored in separately locked, permanently affixed compartments.
A cognitively intact resident with a urostomy and indwelling catheter system was observed on multiple occasions with the open-ended catheter tubing hanging into a trash receptacle, contrary to facility policies on infection prevention and catheter management. The resident reported emptying her own urostomy by attaching the catheter bag tubing to the pouch and placing the tubing over the trash can in case of leakage, and stated she did not perform hand hygiene before or after draining the bag and had not been provided with alcohol-based hand rub or sanitizing wipes. An LPN confirmed the resident’s self-care routine and, upon seeing the tubing in the trash can, acknowledged it was inappropriate and recognized the potential for UTI. The IP, DON, and ED each stated that the tubing being in the trash can was a concern and could lead to infection, indicating a failure to effectively implement the infection prevention and control program for this resident.
Macaroni and cheese and greens were placed on the steam table more than an hour before the scheduled meal, exceeding the facility's policy limit of 30 minutes. The Dietary Manager was unaware of this early placement, and a dietary staff member confirmed the timing. This practice had the potential to affect all residents receiving meals from the kitchen.
Staff did not consistently use required PPE, such as gowns, during high-contact care activities for a resident needing Enhanced Barrier Precautions, and a CNA returned excess ice from a used cup back into a communal ice cooler, exposing all residents on the unit to potential contamination. These actions were contrary to facility infection control policies and were confirmed through observation and staff interviews.
A wound care nurse did not close the window blinds while providing wound care to a resident with paraplegia and limited mobility, leaving the resident exposed to public view from the parking lot. The resident, who was cognitively intact, reported feeling uncomfortable and exposed. Facility leadership confirmed that staff are expected to ensure privacy by closing blinds and curtains before care.
A resident with multiple chronic conditions was found with medication left unattended in her room, including pills on the floor and in her hand while she was asleep. Staff failed to consistently observe the resident taking her medications, and a CNA returned medication from the floor to the resident without notifying nursing staff. The care plan did not address unsupervised medication administration, and facility leadership acknowledged these actions were not acceptable.
Failure to Initiate New PASARR After New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to initiate a new Level I Pre-admission Screening and Resident Review (PASARR) when a resident developed a newly documented serious mental disorder after admission. Facility policy, reviewed on 09/26/2025, stated that all potential admissions must be screened for possible serious mental disorders or intellectual disabilities and that a negative Level I PASARR ends the process unless a possible serious mental disorder or intellectual disability arises later. The resident was admitted with diagnoses including bipolar disorder, delusional disorder, and chronic kidney disease, and had a Level I PASARR completed on admission. Subsequently, a handwritten physician letter dated 03/27/2025 documented that the resident was admitted with a diagnosis of schizophrenia, confirmed by family as having been diagnosed in her 30s. The letter noted the resident experienced hallucinations and delusions with gradual dose reductions of antipsychotic medication, that her symptoms had been re-evaluated, other diagnoses ruled out, and that the schizophrenia diagnosis was to be continued, with psych notes agreeing with this assessment. Despite this new or clarified serious mental disorder diagnosis, the facility did not complete a new Level I PASARR in October 2023 when schizophrenia was added to the chart. During interviews, the Admissions Director acknowledged that a new mental health diagnosis should trigger a new PASARR and that she was unaware it had not been completed, and the Executive Director stated he was unaware that the PASARR had not been done for this resident in 2023.
Failure to Develop and Implement Comprehensive Care Plans for Urostomy and Splint Use
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for multiple residents, and to ensure that identified care plan interventions were actually carried out. For one resident with paraplegia, type 2 diabetes, and neuromuscular bladder dysfunction, observations over two days showed a catheter drainage bag anchored to the bedside with the end of the catheter tubing hanging into a trash can. The resident reported that she emptied her own urostomy by attaching the catheter bag tubing to her pouch and then placing the tubing over the trash can in case of leaking, and that she did not wash her hands before or after draining the bag. She stated the facility had not provided alcohol-based hand rub or sanitizing wipes for her hands or the catheter tubing, and that staff changed her wafer a few times a week. Her care plans addressed urostomy care, risk for UTI, and behavioral issues such as refusing care and hyper-focusing on urostomy bag changes, but there were no interventions related to her self-care of the urostomy, including hand hygiene, despite her being cognitively intact and performing this task herself. Staff interviews confirmed gaps between the written care plan and actual practice for this resident. An LPN stated he provided urostomy care and changed the wafer about every three days, while the resident emptied her own urostomy bag into a catheter bag that staff then emptied. When he observed the catheter tubing hanging in the trash can, he acknowledged it was "not good" and recognized the potential for a UTI. The Infection Preventionist and DON both stated they were not aware that the resident kept the catheter tubing in the trash can and agreed this was a concern and a potential source of infection. The facility’s comprehensive care plan policy required timely, person-centered plans reviewed and revised by an interdisciplinary team, with monitoring for changes in condition that might warrant updates, but the resident’s self-management practices and hand hygiene needs were not incorporated into the care plan interventions. For another resident admitted with COPD, hemiplegia/hemiparesis of the left non-dominant side, and muscle weakness, the record showed a physician order and care plan for a left-hand splint to be worn a specified number of hours per day. However, multiple observations over several days consistently showed the resident not wearing the splint, with the device sitting by the TV. Record review revealed no progress note documentation of staff implementing the hand splint care plan. Staff interviews indicated that restorative aides and nurses were responsible for applying splints and documenting care, and that failure to wear the splint could lead to negative outcomes such as increased contracture and decreased mobility. The DON stated she expected staff to follow care plans and physician orders, including applying splints and monitoring skin integrity and circulation, and acknowledged residents were at risk when care plans were not implemented. A third resident, admitted with hemiplegia and hemiparesis following intracerebral hemorrhage, seizures, and obesity, had physician orders and a care plan for a right resting hand splint and a left arm protector/palm guard to be applied in the morning and removed in the evening. The MDS indicated splint use, and the comprehensive care plan documented a resting right-hand splint and left palm guard related to limited range of motion. Observations on three separate days showed the resident without the right-hand splint in place; the left palm protector was consistently in place, while the right splint was observed on the bedside table pushed against the far wall. A CNA stated the resident should have a splint on the left hand at all times but was unaware of a right-hand splint. An LPN stated restorative CNAs were supposed to put splints on daily but were frequently pulled to work the floor, and she then applied the right-hand splint during the survey, which was the first time it was observed in use. Other staff interviews confirmed that splint use was specified in the TAR, care plan, and Kardex, and that nursing staff were responsible for ensuring correct application. The DON and Executive Director both stated they expected restorative programs and care plans regarding splinting and range of motion to be followed, and acknowledged that failure to apply splints as ordered could cause skin issues and contractures. Across these three residents, the facility’s own policies on comprehensive care plans and restorative nursing required that residents receive treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents’ choices, with RN or LPN supervision of restorative programs. Despite these policies, the survey findings showed that care plans did not fully address actual resident practices (such as self-care of a urostomy and hand hygiene) and that existing care plan interventions (such as ordered splint use) were not consistently implemented or documented in practice.
Failure to Implement Ordered Splinting and Restorative ROM Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered splinting and restorative interventions to maintain or improve range of motion (ROM) for two residents with hemiparesis and limited ROM. Facility policies on upper extremity splints and restorative nursing required provision and management of splints and braces according to professional standards and care plans, and allowed initiation of restorative programs when residents had restorative needs. For one resident with COPD, left-sided hemiplegia/hemiparesis, muscle weakness, and a contracted left hand, the comprehensive care plan and physician’s orders directed use of a left hand splint for up to six hours, later adjusted to four hours, with application in the morning and removal in the evening. Surveyors repeatedly observed this resident over several days without the ordered splint in place, noting that the splint was consistently sitting by the television instead of on the resident’s hand. An LPN stated that restorative aides were responsible for applying splints, but if they were working on the floor, nurses would apply them. She acknowledged there would be a negative outcome if the resident did not wear the splint, explaining that the left hand would get tighter and the splint was intended to prevent the fingers from drawing into a fist. She also acknowledged there was no documentation showing the splint had been applied. The DON stated she expected staff to follow care plans and that residents were at risk when care plans were not implemented, and the occupational therapist confirmed the expectation that charge nurses apply the splint when restorative aides were unavailable and that failure to follow the care plan for contracture splint care would result in a negative outcome. For a second resident admitted with hemiplegia and hemiparesis following intracerebral hemorrhage, seizures, and obesity, there were physician orders and care plan directives for a right resting hand splint and a left palm protector, both to be applied in the morning and removed in the evening. The MDS and restorative program evaluation documented splint use and a restorative program including daily PROM and resting hand splint use to preserve ROM and prevent contracture development. Surveyors observed this resident on multiple occasions without the right resting hand splint in place, while the left palm protector was consistently applied; the right splint was later seen on the bedside table pushed against the far wall. A CNA reported the resident should have a splint on the left hand at all times but was unaware of the right-hand splint. Multiple CNAs and LPNs described that restorative aides usually applied splints but were frequently pulled to work the floor, and that CNAs or nurses would then be responsible for splint application, with instructions available in the Kardex, TAR, and care plan. The DON and Executive Director both stated they expected staff to follow care plans and orders regarding splint use, and the DON stated that failure to apply splints as ordered would cause skin issues and contractures.
Improper Storage and Security of Refrigerated Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to store controlled drugs in separately locked, permanently affixed compartments as required by facility policy and professional standards. During an observation of the Wing 7 medication room, the medication refrigerator was found unlocked while containing multiple bottles of lorazepam 2 mg/ml oral concentrate that were not in a separate lock box or affixed to the inside of the refrigerator. Staff interviews revealed that an LPN acknowledged the refrigerator should have been locked and that there was no lock box available for refrigerated controlled substances. A unit manager and other nursing staff stated they believed the combination of the locked medication room and locked medication refrigerator constituted a two-lock system for narcotics and were not aware that narcotics in the medication refrigerator needed to be in a secure lock box. Subsequent observations showed that when a narcotic lock box was present in the medication refrigerator, it was locked but not permanently affixed to the inside of the refrigerator, contrary to facility policy requiring separately locked, permanently affixed compartments for Schedule II–V medications, including refrigerated controlled substances. Additional interviews with another unit manager confirmed that charge nurses held the keys to the medication refrigerator and that narcotics were counted each shift and witnessed for waste, but did not address the requirement for the lock box to be affixed. The DON and Executive Director both stated their expectation that medication refrigerators be locked and that narcotics be secured in a secondary lock box, and the Executive Director acknowledged awareness that narcotic boxes were supposed to be affixed, but he was not aware they were not affixed. These observations and statements demonstrate that controlled substances, specifically lorazepam, were not consistently stored in separately locked, permanently affixed compartments as required.
Improper Management of Urostomy Catheter Tubing and Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program for a resident with a urostomy and indwelling catheter system. Surveyor observations on multiple days showed that the open-ended catheter tubing connected to the resident’s bedside catheter bag was loosely hanging into a trash receptacle. The tubing was first observed in the trash can in the late afternoon and remained there during subsequent observations the following day. Facility policies on infection prevention and indwelling urinary catheter management required an ongoing program to prevent and control infections and specified that catheter systems should be maintained as closed systems and only changed when clinically indicated, such as when the closed system was compromised. Educational material on urostomy care emphasized hand hygiene before and after touching the pouch and proper handling of the drainage system. The resident, who was cognitively intact and had diagnoses including paraplegia, type 2 diabetes mellitus, and neuromuscular bladder dysfunction, reported that she emptied her own urostomy by attaching the catheter bag tubing to the pouch and then placing the tubing over the trash can in case of leakage. She stated she did not wash her hands before or after draining the bag and had not been provided with alcohol-based hand rub or sanitizing wipes to clean her hands or the catheter tubing. An LPN confirmed that the resident emptied her own urostomy bag into a catheter bag and that staff emptied the catheter bag; upon observing the tubing hanging in the trash can, he acknowledged it was not appropriate and recognized the potential for urinary tract infection. The Infection Preventionist, DON, and Executive Director each stated that the catheter tubing being in the trash can was a concern and could lead to infection, and the Infection Preventionist stated she had not been aware that the resident kept the tubing in the trash can.
Prolonged Holding of Food on Steam Table Compromises Nutritive Value
Penalty
Summary
The facility failed to ensure that the nutritive value of food was maintained and not compromised due to prolonged holding on a steam table. Observations revealed that macaroni and cheese and greens were placed on the steam table over an hour before the scheduled evening meal service, contrary to the facility's policy, which states that food should not be placed on the steam table more than 30 minutes before meal service. The Dietary Manager was unaware that the food had already been placed on the steam table, and a dietary staff member confirmed placing the items on the steam table approximately an hour and twenty minutes before the meal was to be served. This practice had the potential to affect all 163 residents who consumed food from the kitchen.
Failure to Follow Infection Control Procedures and Proper PPE Use
Penalty
Summary
Staff failed to follow infection control procedures for one resident who required Enhanced Barrier Precautions (EBP) and for all residents on a specific unit who used ice from a communal cooler. For the resident requiring EBP, multiple staff members, including CNAs and an RN, did not don the necessary personal protective equipment (PPE), specifically gowns, while performing high-contact care activities such as catheter care, wound care, and gastrostomy tube site care. Despite facility policy and signage indicating the need for EBP, staff either forgot, were unaware, or did not recall the requirement to wear gowns during these procedures. Interviews revealed gaps in staff knowledge and training regarding EBP, with some staff not recognizing when gowns were required or not noticing the signage indicating EBP precautions. Additionally, an infection control breach occurred when a CNA, while delivering ice to residents, overfilled a used resident's cup and poured the excess ice back into the clean ice cooler. This action was observed and acknowledged by the CNA, and it was confirmed by interviews with the Assistant Infection Prevention Nurse and the Director of Nursing that returning unused ice to the cooler was against facility policy. The incident involved all residents on the affected unit who used ice from the contaminated cooler. The deficiencies were identified through direct observation, record review, and staff interviews, which highlighted failures to adhere to established infection prevention and control policies, including the use of PPE during high-contact care and proper handling of communal ice to prevent cross-contamination.
Resident Privacy Not Maintained During Wound Care
Penalty
Summary
A wound care nurse failed to ensure the privacy of a resident during wound care by not closing the window blinds, which left the resident exposed to view from the facility's main entrance parking lot. The incident occurred while the resident, who was admitted with paraplegia, limited mobility, and neuromuscular dysfunction of the bladder, was receiving treatment for wounds on her buttock and foot. The resident was assessed as cognitively intact with a BIMS score of 14 out of 15. During the procedure, the nurse did not ask the resident if she wanted the blinds closed, despite knowing that the resident sometimes refused this in the past. The resident later expressed discomfort and dissatisfaction, stating that she felt exposed and that people walking by could have seen her. Interviews with the wound care nurse, DON, and Administrator confirmed that facility policy and expectations require staff to provide privacy by closing window blinds and privacy curtains before performing care. The DON and Administrator both acknowledged that the nurse's actions failed to protect the resident's dignity and privacy.
Failure to Ensure Safe and Supervised Medication Administration
Penalty
Summary
A deficiency occurred when staff failed to ensure that medication administration was performed in accordance with professional standards and facility policy for one resident. Observations revealed that medication was found under the resident's bed, on her bedside table, and in her hand while she was lying in bed with her eyes closed. The resident reported that a nurse left her medication cup on the bedside table and walked away, after which she accidentally knocked the cup over. A CNA later picked up the medication from the floor and returned it to the cup, which the resident then consumed. The CNA did not notify nursing staff about the medication being on the floor. Review of the resident's medical record showed she was cognitively intact and had multiple diagnoses, including multiple sclerosis, ADHD, and Parkinson's disease. The care plan did not include any intervention for the resident to take medications unsupervised. Medication administration records indicated that all prescribed medications were documented as given, but direct observation and interviews revealed that staff did not consistently witness the resident taking her medications, and medication was left unattended in the resident's room. Further observations on a separate day found the resident again with a medication cup containing multiple pills in her hand and a tablet on the overbed table while she was asleep. Nursing staff admitted that they may have failed to observe the resident taking her medications due to being busy. Facility leadership and infection prevention staff confirmed that residents ingesting medication from the floor and unsupervised medication administration were unacceptable and not in line with facility expectations or training.
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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 Paducah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonecreek Health And Rehabilitation | 1 mi | ★★★★★ | 11 | 0 |
| River Haven Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 6 | 0 |
| Providence Pointe Healthcare | 4.9 mi | ★★★★★ | 0 | 0 |
| Southgate Health Care Center | 7.6 mi | ★★★★★ | 7 | 1 |
| Metropolis Rehab & Hcc | 8.8 mi | ★★★★★ | 41 | 1 |
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