Below 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 Parkdale Manor Health & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to provide sufficient nursing staff to respond to residents’ call lights in a timely manner, despite policies requiring staffing based on resident needs and prompt call light response. Staffing schedules showed only one nurse on duty overnight with the DON functioning as a nurse aide, while many residents required assistance with care. A resident with cerebral palsy and intact cognition, a resident with COPD and fall risk who depended on staff for ADLs, and a resident with an unsteady gait and urinary incontinence all experienced repeated call light response delays ranging from over 30 minutes to more than 90 minutes, leading to episodes of incontinence and significant frustration. Multiple CNAs, an RN, and other staff reported chronic short staffing, heavy workloads, and unsuccessful efforts to obtain agency staff, and the DON confirmed she frequently worked direct care shifts and that the facility’s goal of answering call lights within 5–15 minutes was not being met.
The facility did not maintain or implement an ongoing QAPI program as required by policy, with the Administrator confirming that no Performance Improvement Projects were underway due to staffing shortages. While some meetings on risk and infection control occurred, there was no structured QAPI process in place to identify or address care concerns for the 28 residents.
The facility did not ensure its QAPI committee met quarterly or worked on performance improvement projects (PIPs) as required by policy. Interviews revealed that, due to staffing shortages, there was no active QAPI program or documentation of QAPI activities, and key committee members, including the Medical Director, had not participated in QAPI meetings. This deficiency had the potential to impact the quality of care for all 28 residents.
The facility did not provide the required Medicare notifications (SNF ABN and NOMNC) to two residents when their Medicare Part A coverage for skilled services was ending or not covered. In both cases, the necessary forms were either not issued or could not be located, and there was no documentation of communication with the residents or their representatives about potential financial liability.
Two residents who were fully dependent on enteral nutrition had their feeding bags running without required labels indicating formula type, rate, time hung, or the initials of the nurse who hung them. Observations and staff interviews confirmed that the facility's policy for labeling enteral feeding bags was not followed.
A resident with new diagnoses of major depressive disorder and bipolar II disorder did not have an updated PASARR Level One completed to reflect these changes. The original PASARR form was incomplete, and despite new psychiatric medications and documentation, no new screening was initiated. Social Services staff confirmed the oversight, and no PASARR policy was available when requested.
A resident was admitted without a fully completed PASARR Level One screening, as the required medical and psychiatric questions were left blank and the screening result was not indicated. Social Services staff confirmed the form was incomplete, despite facility policy requiring comprehensive screening for mental disorders, intellectual disabilities, or related conditions.
A resident with limited mobility and a preference for showers did not receive scheduled showers on multiple occasions, despite being cognitively intact and requiring maximal assistance for ADLs. Facility records and staff interviews confirmed missed showers, with no documentation of refusals and no consistent staff assignment for providing showers, resulting in unmet personal hygiene needs.
A resident with significant nutritional needs and dependent on tube feeding did not have weekly weights obtained or documented as ordered, despite repeated recommendations from the RD. Gaps in communication among nursing staff, lack of awareness of equipment failure, and missed implementation of physician orders led to inadequate monitoring of the resident's weight status.
A resident requiring continuous oxygen therapy was found to have an oxygen concentrator with heavily soiled inlet filters, despite facility policy mandating weekly cleaning. Both RN and DON confirmed the filters were not clean and acknowledged nursing responsibility for their maintenance.
A resident's surgical staples were not removed in a timely manner, despite being charted as completed, leading to a delay of five weeks. Weekly skin assessments failed to identify the oversight, and a follow-up appointment was missed due to a misunderstanding. The facility also faced issues with obtaining x-ray results and lacked staple removal kits, which were eventually provided by the resident's family.
Insufficient Nursing Staff Leading to Prolonged Call Light Response Times
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff, including aides, to respond to residents’ call lights in a timely manner, despite policies requiring staffing based on resident needs and prompt call light response. The facility’s staffing policy states that staffing levels and competencies must be determined by resident care plans and the facility assessment, and its call light policy requires staff to respond promptly, ideally completing requests within five minutes when possible. However, staffing schedules on multiple dates showed only one nurse on duty from 6:00 P.M. to 6:00 A.M., with the DON working as a nurse aide during those hours, and on one date only one nurse and one nurse aide were scheduled overnight, even though 19 of 30 residents required assistance with care. Resident #1, who had intact cognition, limited physical mobility related to cerebral palsy, and required assistance with transfers to the toilet but was continent of bowel and bladder, experienced prolonged call light response times. Call light logs showed that on three separate dates, staff took between approximately 35 and 48 minutes to turn off the resident’s call light. The resident reported that there were not enough staff to care for him/her, that he/she had waited so long for staff to respond that he/she wet the bed, and that this caused frustration and embarrassment because he/she could remain continent if staff assisted to the bathroom in time. Resident #2, cognitively intact with limited mobility due to weakness and COPD, at risk for falls, and dependent on staff for ADLs, had multiple call light activations with response times ranging from about 42 to nearly 100 minutes. The resident stated there was not enough staff, that call lights sometimes took one and a half to two hours to be answered, and that he/she was frustrated and could not count on staff to respond. Resident #3, cognitively intact with an unsteady gait, multiple prior falls, and urinary incontinence related to impaired mobility, also experienced delayed responses, including waits of about 32 and 56 minutes, and reported wetting his/her pants while waiting, feeling angry and embarrassed. Multiple staff, including CNAs, an RN, and an anonymous staff member, reported that staffing had been consistently short, that several staff had quit due to heavy workloads, and that attempts to obtain agency staff were not allowed. The DON confirmed she frequently worked as a charge nurse or aide due to low staffing and acknowledged that the facility’s goal of answering call lights within 5–15 minutes was not being met with current staffing levels.
Failure to Maintain and Implement QAPI Program
Penalty
Summary
The facility failed to ensure the implementation and maintenance of an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program as required by its own policy. The policy, last revised in April 2014, mandates the development and active pursuit of quality of care and quality of life goals through QAPI activities. During an interview, the Administrator acknowledged that no Performance Improvement Projects (PIPs) were currently in progress, citing insufficient staffing as the reason for not conducting QAPI activities. Although the Administrator mentioned that various meetings, such as risk, infection control, and clinical meetings, were held to discuss and review topics, there was no dedicated staff or structured process in place for QAPI. This deficiency affected the facility's ability to identify, maintain, and evaluate concerns related to effective resident care for all 28 residents in the census.
Failure to Maintain Active QAPI Committee and Performance Improvement Projects
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee met on a quarterly basis to work on performance improvement projects (PIPs) and track their progress, as required by facility policy. The policy outlined that the QAPI committee should be composed of various representatives, including the Administrator, DON, Medical Director, and others, and should systematically identify, resolve, and monitor deficiencies in resident care and services. However, interviews and policy review revealed that the committee was not actively meeting or documenting QAPI activities, and there was no evidence of an ongoing QAPI program. During interviews, the Administrator acknowledged that while staff had been meeting for other purposes, such as risk and infection control, there was no dedicated QAPI activity due to staffing shortages. The Administrator also confirmed that the committee had not been working on any PIPs and that the only recent meeting was to discuss starting QAPI. Additionally, the Medical Director reported not having participated in any QAPI meetings since assuming the role. This lack of an active QAPI program had the potential to affect the quality of care and services for all 28 residents in the facility.
Failure to Provide Required Medicare Coverage Notices to Residents
Penalty
Summary
The facility failed to provide required Medicare notifications to residents when Medicare Part A coverage for skilled services was ending or not covered. Specifically, for two out of three residents reviewed, the facility did not issue the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, CMS-10055) or the Notice of Medicare Non-Coverage (NOMNC, CMS-10123) as required by policy. In one case, a resident's Medicare Part A skilled services episode ended before benefit days were exhausted, and the SNF ABN was not provided due to oversight. There was no documentation in the electronic medical record indicating that the resident or their representative was informed about potential additional costs if they chose to continue services. In another case, a resident's Medicare Part A skilled services episode ended voluntarily, and the NOMNC was not provided, also due to oversight. Again, there was no documentation of communication with the resident or representative regarding potential financial liability. Interviews with facility staff confirmed that the required forms were either not provided or could not be located, and staff were not fully aware of the requirements for issuing these notifications.
Failure to Label and Date Enteral Feeding Bags for Two Residents
Penalty
Summary
The facility failed to properly label and date enteral feeding bags for two residents who required tube feedings. Both residents were totally dependent on nursing staff for their nutrition and had orders for specific enteral formulas and rates. Observations revealed that the enteral feeding bags in both residents' rooms were running but were not labeled with the type of formula, the rate, the time the formula was hung, or the initials of the nurse who hung the bag. This was confirmed during interviews with nursing staff, who acknowledged that the bags should have been labeled according to facility policy. Review of the residents' medical records showed that both had significant medical conditions requiring enteral nutrition, including respiratory failure, malnutrition, gastrostomy status, and dysphagia. The facility's policy required that enteral feeding bags be labeled with the formula type, date and time hung, and the initials of the nurse, but this was not followed. The Director of Nursing confirmed that the night nurses were responsible for hanging and labeling the enteral feeding bags for these residents.
Failure to Update PASARR Level One Following New Psychiatric Diagnoses
Penalty
Summary
The facility failed to initiate a new Pre-Admission Screening and Resident Review (PASARR) Level One for a resident after the development of new psychiatric diagnoses. Record review showed that the resident was originally admitted with a PASARR Level One form that was incomplete, as the medical and psychiatric questions were left unanswered and the result was not indicated. Subsequently, the resident was diagnosed with major depressive disorder and bipolar II disorder, and was prescribed medications including divalproex and Cymbalta for these conditions. The resident's electronic medical record also contained several psychiatric notes and quarterly MDS assessments reflecting these diagnoses. Despite these new diagnoses and ongoing psychiatric care, there was no updated PASARR Level One completed to reflect the resident's current mental health status. During an interview, the Social Services staff confirmed that a new screening should have been completed with each new diagnosis, but this was not done. Additionally, when requested, neither the Administrator nor the Social Services staff could provide a PASARR policy.
Incomplete PASARR Level One Screening for Admission
Penalty
Summary
The facility failed to provide a complete PASARR (Pre-Admission Screening and Resident Review) Level One screening for a resident admitted to the facility. Record review showed that the PASARR Level One form, signed by the hospitalist prior to admission, had all demographic fields completed, but the medical and psychiatric questions were left unanswered and the form did not indicate whether the screening result was positive or negative for the need for a PASRR Level Two. The resident's medical diagnoses included morbid obesity and dysphagia, with no reference to a psychiatric diagnosis in the medical record. During an interview, Social Services staff confirmed that the PASARR Level One form in the resident's chart was incomplete, with no psychiatric questions answered and no indication of the screening result. The facility's policy requires all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related conditions per the Medicaid PASARR process, but this was not followed in this instance.
Failure to Provide Scheduled Showers per Resident Preference
Penalty
Summary
The facility failed to ensure that a resident received showers according to their stated preference and care plan, resulting in missed personal hygiene care. The resident, who had a history of stroke with left-sided hemiplegia and major depression, required maximal assistance from two staff members for activities of daily living (ADLs) and had an intact cognitive status. The care plan specified a preference for showers, and the resident was scheduled to receive showers three times a week. However, documentation and interviews revealed that the resident did not receive scheduled showers on multiple occasions over a period of several weeks, with no evidence that the resident refused these showers. Staff interviews indicated that there was no consistent assignment for providing showers, and the process relied on staff volunteering, leading to lapses in care. The CNA responsible for showers did not document refusals, and the RN was unable to provide documentation or describe a process for ensuring showers were provided as scheduled. The DON confirmed that the resident reported not receiving a shower in six days, which was corroborated by the facility's own records.
Failure to Obtain and Document Weekly Weights for Tube-Fed Resident
Penalty
Summary
The facility failed to follow recommendations to obtain weekly weights for one resident who was dependent on enteral feeding and had diagnoses including acute and chronic respiratory failure and moderate protein-calorie malnutrition. Despite multiple recommendations from the Registered Dietician (RD) to monitor weekly weights, the facility did not consistently obtain or document these weights as ordered by the physician and recommended by the RD. The resident's care plan and physician orders specified weekly weights, but the electronic medical record showed gaps, with weights only recorded sporadically over several months. Interviews revealed that the nursing department was responsible for ensuring weights were obtained, but the Restorative Aide, who was tasked with weighing residents, was not informed of the weekly weight order for this resident. Additionally, the lift required to weigh the resident was broken, and facility leadership, including the DON and Administrator, were unaware of the equipment issue and the missed weights. The Medical Director was also not aware of the equipment problem and expected staff to follow signed orders for weekly weights.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
A deficiency was identified when a resident with diagnoses including solitary pulmonary nodule, chronic respiratory failure with hypercapnia, and asthma was observed to have an oxygen concentrator in their room with both inlet filters covered in a large buildup of white lint and heavy debris. The facility's policy required that oxygen concentrator filters be washed every seven days with soap and water, rinsed, and squeezed dry. However, observations on multiple days revealed that the filters remained very dirty and had not been cleaned as required. Interviews with staff confirmed the deficiency, with a registered nurse acknowledging that the filters should not appear dirty and stating that it was ultimately the nurse's responsibility to ensure cleanliness. The Director of Nursing also confirmed the filters were not clean and indicated that the night nurse on Sunday nights was responsible for weekly cleaning. The failure to maintain clean oxygen concentrator filters was directly observed and confirmed by both nursing staff and facility leadership.
Failure to Remove Surgical Staples in a Timely Manner
Penalty
Summary
The facility failed to adhere to professional standards of practice for a resident who had undergone surgery to correct broken bones in both legs. The resident's surgical incisions were closed with staples, and provider orders specified that these staples should be removed on a specific date. However, the facility staff charted the staple removal as completed on the designated date, although the staples were not actually removed until five weeks later. During this period, weekly skin assessments were documented as complete, yet the staff did not recognize or report the presence of the staples, which could have delayed the resident's healing process. Additionally, the facility did not provide policies and procedures related to physician orders and weekly skin assessments. The resident missed a scheduled follow-up appointment due to a misunderstanding about the nature of the appointment, and the facility administration was unaware of the oversight until several weeks later. The facility also faced issues with obtaining x-ray results, as the mobile x-ray company could not provide the results in the required format. The facility administrator, who was also acting as the social services director due to staffing issues, acknowledged these lapses and the lack of staple removal kits, which were eventually provided by the resident's family.
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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 Maryville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village Care Center Inc | 1.1 mi | ★★★★★ | 1 | 0 |
| Maryville Living Center | 1.6 mi | ★★★★★ | 5 | 0 |
| Nodaway Healthcare | 4.1 mi | ★★★★★ | 2 | 0 |
| Pine View Manor Inc | 20.4 mi | ★★★★★ | 1 | 0 |
| Tiffany Heights | 22.5 mi | ★★★★★ | 15 | 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.