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 Home during CMS and state inspections, most recent first.
Failure to complete a bed hold for a resident after hospital admission. A resident with emphysema, heart disease, CHF, DM, dysphagia, and CKD became increasingly fatigued and weak, was taken to the clinic by family, and was later admitted to acute care for pneumonia. The facility received notice of the hospitalization, but there was no indication a bed hold was completed verbally or in writing, despite policy stating residents leaving for hospitalization and choosing to return were to complete a bed hold.
Failure to revise care plans for two residents left key safety and behavior needs undocumented. One resident with dementia had scissors removed after cutting clothing and hair, but the care plan did not include supervised scissor use. Another resident with a wander guard repeatedly wanted to go outside and attempted to go out on his own, but the care plan did not identify elopement risk or specific interventions for staff. Interviews confirmed staff knew about both residents’ needs, yet the care plans did not reflect those changes.
A resident with COPD, respiratory failure with hypoxia, and sleep apnea had nebulizer treatments documented as complete even though the nebulizer cup still contained medication during observations. Staff found the nebulizer left assembled on the resident’s end table, and an RN and LPN confirmed medication remained in the cup. A self-administration assessment stated the resident was not safe to self-administer inhalants without supervision, but the record was not updated to reflect that change, and the facility’s nebulizer policy required staff to remain with the resident and clean the equipment after use.
A resident with intact cognition and diagnoses including CHF, COPD, respiratory failure with hypoxia, O2 dependence, sleep apnea, and A-fib had inconsistent documentation about the ability to self-administer nebulizer treatments. The MAR stated the resident could self-administer meds and nebulizers after set-up, but a self-administration assessment found the resident was not safe to self-administer inhalants without supervision. Surveyors also observed a handheld nebulizer still connected with medication remaining in the cup, while the MAR showed the treatment as completed and signed off by an RN.
A resident with COPD, respiratory failure with hypoxia, and other cardiac and respiratory diagnoses had a handheld nebulizer left on her end table with medication still in the cup after treatments. Staff documented the treatment as completed, but an RN later observed the cup still contained a moderate amount of medication and stated the nebulizer should have been disassembled and rinsed after use. The next morning, the nebulizer was again found assembled with medication remaining while the resident was asleep, despite a prior self-administration assessment stating she was not safe to self-administer inhalants without supervision.
The facility did not ensure that data presented to the QAPI committee was analyzed or documented, nor were benchmarks or action plans established for most quality indicators. While department heads brought data on various topics, only falls and pressure ulcers had identified goals, and even these lacked analysis or follow-up actions, resulting in insufficient oversight for all residents.
The facility did not provide documentation of a required Performance Improvement Project (PIP) focused on high risk or problem-prone areas, as shown by a review of QAPI meeting minutes and confirmed by a regional administrator. No goal, action plan, or staff training was completed for the identified PIP, and the deficiency had the potential to affect all 18 residents.
The QAPI committee did not receive a required infection control program report from the infection preventionist for one quarter, as no data was presented at the April meeting despite the DON/infection preventionist being present. The administrator, who was new to the role and unaware of the omission, confirmed attendance at the meeting. No policy was available regarding infection preventionist reporting at QAPI meetings.
The facility did not adequately track employee illnesses or ensure proper documentation of symptoms, physician visits, and clearance before staff returned to work. Additionally, two new hires did not complete the required two-step TB testing, with only the first step documented in their files.
The facility did not ensure that the acting IP, who was also the interim DON, had completed specialized training or certification in infection prevention and control. Interviews and document review confirmed that there was no certified IP working at least part-time or onsite, and the facility was still recruiting for qualified staff to oversee the infection control program. This deficiency had the potential to affect all residents in the facility.
The facility did not provide mandatory training to staff on its specific QAPI program, including its goals, elements, and staff roles. Interviews showed that while some staff completed general QAPI training online, none received information about the facility's own QAPI initiatives, and no policy or evidence of such training was provided. This affected all residents.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall and had a swollen hand from a previous, undocumented injury. Facility staff did not complete required documentation or report the injury of unknown origin to the State Agency as mandated by policy. Interviews confirmed that the incident was neither adequately investigated nor reported within the required timeframe.
A resident with severe cognitive impairment and a history of falls and aggression sustained a right middle finger fracture of unknown origin. Staff were unaware of how the injury occurred, and there was no evidence of an internal investigation or incident report, nor was the injury reported to the State Agency as required by facility policy.
Failure to Complete Bed Hold After Hospitalization
Penalty
Summary
The facility failed to obtain a bed hold for 1 of 4 sampled residents, R24, after he was hospitalized. R24 had an unplanned short-term general hospital stay beginning on 4/2/26, and his 4/6/26 quarterly MDS showed his cognition was intact, he was independent with set-up assistance for ADLs except for lower-body dressing, and he ambulated independently without assistive devices. His diagnoses included emphysema, heart disease with high blood pressure, CHF, diabetes, difficulty swallowing, and CKD. Progress notes documented that on 4/2/26 he was increasingly fatigued, weak, and was taken to the clinic by family; later that day the facility received a phone call that he had been admitted to acute care for pneumonia. On 4/3/26, he remained hospitalized and was discharged from the facility with return anticipated. Interview with the nursing consultant and interim DON confirmed a bed hold should have been completed when the facility was notified of the hospital admission, and there was no indication that a bed hold had been completed verbally or in writing. The February 2024 Bed Hold Responsibilities policy stated residents leaving due to hospitalization or therapeutic leave and choosing to return were to complete a bed hold, but it did not identify the process for completion.
Failure to Revise Care Plans for Safety and Elopement Needs
Penalty
Summary
The facility failed to revise the care plan for 2 of 12 sampled residents, R15 and R18, after changes in condition and identified needs were documented. The report states the care plan was not updated within 7 days of the comprehensive assessment and was not prepared, reviewed, and revised by a team of health professionals as required. Review of the records and interviews showed that the existing care plans did not reflect the residents’ current assessed needs and behaviors. For R15, the 4/6/26 quarterly MDS showed severely impaired cognition, with independence in dressing, toileting, and ambulation using a walker, and diagnoses including Alzheimer’s disease, dementia, muscle weakness, hallucinations, anxiety disorder, and long-term pain medication use. On 5/4/26, R15 stated the facility had taken away her scissors and she could no longer use them for knitting, while a bag of yarn and string was observed near her recliner. A 4/15/26 progress note documented housekeeping staff reported R15 had been cutting her clothes and had cut her hair, and social services noted a plan for supervised scissor use. R15’s care plan addressed leisure preferences and one-to-one interactions, but it did not include supervised assistance with scissors for safety reasons. The IDON confirmed R15 had been cutting her clothing and hair, was not safe to use scissors unsupervised, and that the care plan should reflect that need. For R18, the 5/6/26 quarterly MDS showed a BIMS score of 13, indicating cognition intact, with independence in dressing, toileting, and ambulation using a walker, wandering noted during the assessment period, and use of oxygen and multiple medications including antipsychotic, antidepressant, hypnotic, anticonvulsant, pain, and antiplatelet drugs. On 5/4/26, R18 stated he had an alarm on, wanted to go outside, and believed it was illegal that he could not go out by himself; he also said staff told him he needed someone to go outside with him but there was never anyone available. His care plan noted cognition-related needs and a wander guard, but it did not identify elopement risk, a goal, or interventions for what staff should do if he attempted to leave or when he wanted to go outside. The elopement evaluation left the risk for wandering and/or elopement blank, and interviews confirmed staff knew he wanted to go outside, sometimes attempted to go out on his own, and that the care plan lacked detailed interventions.
Nebulizer Treatment Not Fully Supervised or Completed
Penalty
Summary
The facility failed to ensure medication administration was completed and supervised as ordered for one sampled resident who used a nebulized medication. The resident had an intact cognition and diagnoses of COPD, respiratory failure with hypoxia, and sleep apnea, and required moderate assistance with transfers, dressing, and hygiene. On one observation, the resident’s handheld nebulizer was found on the end table still connected to the machine with approximately half of the medication remaining in the cup, even though the MAR showed the treatment had been documented as completed hours earlier by an RN. The RN who observed the setup stated nursing should have followed up to ensure the medication was fully administered and that the nebulizer should have been disassembled and rinsed after use. A second observation the next morning again found the resident’s nebulizer assembled on the end table with about one-quarter of the medication still in the cup while the resident was asleep in bed. The LPN confirmed the nebulizer was still present with medication remaining and reviewed the MAR, which showed the last treatment had been given overnight. A self-administration assessment completed after the resident returned from the hospital stated the resident was not capable of self-administering inhalants or using inhalers without supervision and was not safe to self-administer at that time. The consultant who completed the assessment acknowledged the resident’s record was not updated to reflect that she was no longer safe to self-administer nebulizer treatments, and the interim DON stated staff were expected to follow the facility’s nebulizer policy requiring staff to remain with the resident during the procedure and clean the nebulizer after completion.
Inconsistent documentation of self-administration status for nebulizer treatments
Penalty
Summary
The facility failed to ensure documentation of one sampled resident’s ability to self-administer medication was consistent and accurate throughout the medical record. The resident’s quarterly MDS, accepted on 4/6/26, identified intact cognition and multiple diagnoses including heart failure, COPD, respiratory failure with hypoxia, dependence on supplemental oxygen, sleep apnea, and atrial fibrillation. The resident required moderate assistance from one staff member for transfers, dressing, and hygiene. On 5/4/26 at 5:30 p.m., surveyors observed a handheld nebulizer in the resident’s room still connected to the nebulizer machine, with approximately half of the medication remaining in the cup, while the resident was not present. The May 2026 MAR documented that the resident received an ipratropium/albuterol nebulizer treatment at 2:00 p.m. and that RN-B signed off the treatment as completed. The MAR also stated the resident was able to self-administer oral medications and nebulizers after set-up. However, the resident’s 4/13/26 self-administration assessment completed by RN Consultant-B stated the resident was not capable of self-administering inhalants or using inhalers without supervision and was not safe to self-administer at that time. During interview, RN Consultant-B acknowledged the assessment was accurate and agreed he did not update the MAR to show the resident was no longer safe to self-administer nebulizer treatments. The interim DON stated it was her expectation that the MAR be updated immediately following the change with re-assessment.
Nebulizer Cup Left Unrinsed With Medication Remaining After Treatment
Penalty
Summary
The facility failed to ensure a nebulizer medication cup was rinsed and left to air dry after medication administration for a resident with intact cognition and diagnoses including heart failure, COPD, respiratory failure with hypoxia, dependence on supplemental oxygen, sleep apnea, and atrial fibrillation. The resident required moderate assistance with transfers, dressing, and hygiene, and her quarterly MDS identified she was able to self-administer oral medications and nebulizers after set-up. However, a self-administration assessment completed on 4/13/26 stated she was not capable of self-administering inhalants or using inhalers without supervision and was not safe to self-administer at that time. On 5/4/26, the resident’s handheld nebulizer was observed on her end table still connected to the machine, with approximately half of the medication remaining in the cup, about 3 hours and 45 minutes after the scheduled 2:00 p.m. treatment. RN-A agreed the cup still contained a moderate amount of medication and stated nursing should have followed up to ensure the full dose was administered and the nebulizer should have been disassembled and rinsed after completion. On 5/5/26, the nebulizer was again observed on the end table with approximately one-fourth of the medication remaining in the cup while the resident was asleep in bed. LPN-A confirmed no medication had yet been given that morning and noted the last nebulizer treatment had been during the night at 1:20 a.m. The interim DON stated staff were expected to remain with the resident to ensure the entire dose was administered and to follow the facility nebulizer therapy policy, which required disassembly, rinsing with warm water, and air-drying after use.
Failure to Analyze and Document QAPI Data and Actions
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was properly analyzed and documented. Although department heads regularly brought data on topics such as medication errors, falls, pressure ulcers, weight loss, pharmacy services, infection control, admissions and discharges, staff agency use, and adverse event monitoring to the QAPI meetings, only falls and pressure ulcers had benchmark goals identified. Even for these areas, there was no analysis of the data or documentation of actions the facility would take to achieve the goals, nor was there monitoring to determine if the goals were met or if continued QAPI oversight was needed. For all other areas, there were no documented benchmarks, data analysis, or action plans. Review of QAPI meeting minutes from multiple months confirmed the lack of documented benchmarks, analysis, and action plans across a range of quality indicators. An interview with the regional administrator confirmed that the facility had not identified goals, action plans, or analyzed data brought forth in the QAPI meetings. The facility's own QAPI policy required oversight, action plan development, and analysis, but these steps were not documented or implemented as required.
Lack of Evidence for Required Performance Improvement Project
Penalty
Summary
The facility failed to provide evidence of a Performance Improvement Project (PIP) that addressed high risk or problem-prone areas, as required by their Quality Assurance and Performance Improvement (QAPI) policy. Review of QAPI meeting minutes over a five-month period showed that no PIP projects were documented. During an interview, the regional administrator confirmed that although a PIP project had been identified, no goal was set, no action plan was developed, the project was not discussed in QAPI meetings, and staff had not been trained. The facility's QAPI policy requires the committee to oversee improvement areas, develop action plans, and maintain documentation of ongoing QAPI activities, including at least one distinct PIP project annually. This deficiency had the potential to affect all 18 residents in the facility.
QAPI Committee Did Not Receive Required Infection Control Report
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee failed to receive a report from the infection preventionist regarding the infection control program for one of the three quarters reviewed. Specifically, during the April QAPI meeting, no data or report on the infection control program was presented for committee review, as confirmed by the meeting minutes. The sign-in sheet for the April meeting showed that the DON, who was also serving as the infection preventionist, was present. During an interview, the administrator stated he was unaware that the infection preventionist had not provided the required data or report and confirmed his own attendance at the meeting. He also noted recent staff turnover, including the resignation of the social service designee and the interim status of the DON, and indicated he had only recently obtained his administrator license. No policy was provided regarding the requirement for the infection preventionist to present infection control data at QAPI meetings.
Deficient Employee Illness Tracking and TB Testing
Penalty
Summary
The facility failed to properly track and document employee illnesses, resulting in incomplete surveillance of staff health status and return-to-work criteria. Employee Absence Report sheets reviewed for April 2025 showed missing or incomplete information regarding symptoms, physician visits, COVID testing, and resolution of illness for several staff members, including nurse aides, the activity director, the administrator, and an LPN. In multiple cases, there was no documentation of when or if symptoms resolved, whether staff were cleared to return to work, or if required testing was performed. The interim DON confirmed that employee illness surveillance was not adequately completed, and the existing policy required staff to report illness and obtain clearance before returning, but this was not consistently followed. Additionally, the facility did not ensure that two of five sampled employees, a certified nursing assistant and a dietary aide, completed the required two-step tuberculosis (TB) testing upon hire. Both employees had a baseline TB symptom screening and a first-step TST, but there was no evidence of a second TST as required by state guidelines. The facility's TB screening policy referenced CDC recommendations and required baseline risk assessment, symptom evaluation, and TB testing for all new hires, but these procedures were not fully implemented for the affected staff.
Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to ensure that the acting infection preventionist (IP), who also served as the interim director of nursing (DON), had completed specialized training or certification in infection prevention and control. During interviews, the interim DON confirmed that she was responsible for overseeing the infection control program but had not completed the required IP training and certification. Additional interviews with facility staff and the regional administrator revealed that there was no certified IP working at least part-time or onsite at the facility. Document review showed that the facility was actively recruiting for a permanent DON and an assistant director of nursing (ADON) to oversee the infection control program, with job postings specifying the need for education, training, experience, or certification in infection control. The facility's Infection Surveillance-Overview policy outlined the responsibilities of the IP, including leading surveillance, documenting and monitoring findings, providing staff training, and tracking communicable diseases among residents and staff. However, the lack of a qualified and certified IP had the potential to affect all 18 residents residing in the facility.
Lack of Facility-Specific QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training to all staff on its specific Quality Assurance and Performance Improvement (QAPI) program. Interviews with various staff members, including a nursing assistant, dietary aide, and activity aide, revealed that while some had completed general QAPI training through an online platform, none had received training specific to the facility's own QAPI program, its goals, elements, or implementation. Staff were unaware of what the facility was currently working on regarding QAPI, and there was no evidence or policy provided to show that such training had occurred. The regional administrator confirmed that no staff training specific to the facility's QAPI program had been conducted. This deficiency had the potential to affect all 18 residents in the facility.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its own policies and regulatory requirements for timely reporting of suspected abuse, neglect, or injury of unknown origin to the State Agency (SA) for one resident. A resident with severe cognitive impairment, dementia, and a history of falls experienced an unwitnessed fall from a Broda chair while unattended in the day room. Although no new injury was noted from this fall, the resident's right hand remained swollen from a previous finger fracture, the cause of which was undocumented and unwitnessed. Interviews with staff, including a nursing assistant and the DON, revealed a lack of awareness regarding the resident's recent falls and the origin of the hand injury. The DON was unable to provide documentation of the incident or evidence that it had been reported to the SA, as required by facility policy. The administrative consultant and facility administrator both acknowledged that the injury of unknown origin should have been investigated, documented, and reported to the SA, but confirmed that this process was not completed. Review of facility policies and posted guidance indicated that suspected abuse or reportable incidents, including injuries of unknown origin, must be reported to the SA within two hours of discovery. The facility's internal investigation policy outlined steps for conducting investigations, but in this case, there was no adequate investigation or timely reporting of the incident involving the resident's hand injury, resulting in noncompliance with both facility policy and regulatory requirements.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and a history of falls and physical aggression. The resident, who required extensive to total assistance with activities of daily living and had diagnoses including dementia and depression, was found to have swelling and discoloration in his right hand. Progress notes indicated that the resident was unable to communicate the cause of the injury, and staff were unaware of how the injury occurred. Despite documentation of the injury and subsequent diagnosis of a closed, displaced fracture of the right middle finger, there was no evidence of an internal investigation or incident report regarding the injury. Interviews with nursing staff and the DON revealed that the injury was not witnessed, and there was no documentation or report made to the State Agency (SA) as required by facility policy. The DON and consulting administrator both acknowledged that the injury should have been investigated and reported, but confirmed that no such actions were taken. The facility's risk management records and electronic medical record did not contain any documentation of an investigation or incident report related to the injury. The facility's policy on conducting internal investigations outlines steps such as reviewing documents, interviewing staff and residents, and collaborating with administration or outside authorities. However, these procedures were not followed in this case, as there was no evidence of an investigation or reporting of the resident's injury of unknown origin, despite the resident's vulnerability and inability to communicate the cause of the injury.
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 27 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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 Belview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avera Granite Falls Care Center | 1 mi | ★★★★★ | 5 | 0 |
| Luther Haven | 12.6 mi | ★★★★★ | 2 | 0 |
| Clarkfield Care Center | 13.2 mi | ★★★★★ | 5 | 0 |
| Clara City Care Center | 13.3 mi | ★★★★★ | 9 | 1 |
| Renville Health Services | 16.4 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Parkview Home.
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.