Above 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 Parkview Health Care Facility during CMS and state inspections, most recent first.
A resident's dignity was compromised when their catheter bag was repeatedly left uncovered and visible from the hallway, contrary to facility policy. Despite staff acknowledging the importance of using dignity bags, the catheter bag was observed uncovered on multiple occasions. The resident had an indwelling catheter due to conditions like benign prostatic hyperplasia and kidney failure.
A resident with a history of asthma, COPD, and recent pneumonia did not receive scheduled albuterol breathing treatments due to a failure in updating physician orders in the EMR. Despite the resident's requests and physician approval, the facility staff did not consistently administer the medication, leading to the resident experiencing congestion and breathing difficulties. Interviews with staff revealed issues with communication and procedure adherence, contributing to the deficiency.
A resident with multiple pressure wounds received inadequate care due to inconsistent documentation and untimely care planning. Despite being at risk for pressure ulcers, the facility failed to document and assess the resident's wounds properly, leading to their deterioration. Staff interviews revealed a lack of clarity in wound care responsibilities and delayed communication about the resident's worsening condition.
A resident with severe cognitive impairment and declining mobility was repeatedly transferred using a sit-to-stand lift, despite prior falls and recommendations to switch to a Hoyer lift. The facility failed to update the care plan and ensure proper communication and adherence to safety protocols, resulting in continued unsafe transfer attempts.
A facility failed to provide standard respiratory care for a resident using a CPAP machine. The resident, diagnosed with chronic respiratory failure, did not have physician orders for cleaning the CPAP equipment, which had not been cleaned since admission. Staff interviews revealed inconsistencies and lack of clarity in cleaning procedures, with the DON stating that daily cleaning orders should be in place.
A facility failed to document an assessment for entrapment risk and obtain informed consent before using bed rails for a resident with acute metabolic acidosis. Despite the care plan indicating bed rail use for assistance, no documentation was found. Staff interviews revealed inconsistencies in understanding procedures for bed rail assessments and consent, with the Maintenance Director completing an assessment only after installation.
A facility failed to maintain effective infection control as staff did not follow hand hygiene procedures or handle equipment properly, risking infection transmission. A resident with pressure ulcers and an indwelling catheter was affected, as staff entered the room without sanitizing hands, placed a catheter bag on the floor, and did not change gloves during care. Interviews with staff revealed awareness of policies, but practices did not align, indicating a gap in adherence.
The facility failed to implement effective infection control practices during wound care for two residents, leading to potential contamination risks. Staff did not use enhanced barrier precautions, such as gowns and gloves, and failed to follow proper hand hygiene and equipment disinfection protocols. The facility had not yet established policies for enhanced barrier precautions, contributing to these deficiencies.
Failure to Maintain Resident Dignity by Covering Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring that the resident's catheter bag was covered with a dignity bag when visible to others. This deficiency was observed multiple times over several days, with the catheter bag draining pale yellow urine being visible from the hallway through the open door of the resident's room. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and respect, which includes ensuring privacy regarding personal care. The resident involved had been admitted with diagnoses including acute metabolic acidosis, benign prostatic hyperplasia, and kidney failure, and was using an indwelling catheter. Despite the care plan's instructions to monitor and position the catheter bag appropriately, the catheter bag was repeatedly left uncovered and visible. Interviews with various staff members, including a CNA/RMT, RMT, LPN, the DON, and the Administrator, confirmed that catheter bags should be covered with dignity bags at all times to prevent visibility from the hallway.
Failure to Administer Breathing Treatments as Ordered
Penalty
Summary
The facility failed to provide care to a resident according to the physician's orders and the resident's preferences, resulting in a deficiency. The issue arose when staff did not transcribe a physician's order change for breathing treatments into the electronic medical records (EMR) and failed to administer the treatments as ordered. The resident, who had a history of asthma, COPD, and recent pneumonia, was admitted to the facility and required albuterol breathing treatments twice a day, as per their request and physician's approval. However, the staff did not update the order from 'as needed' to 'scheduled twice daily,' leading to inconsistent administration of the medication. The resident's treatment administration record (TAR) showed multiple instances where the albuterol was not administered as scheduled, despite the resident's repeated requests and the physician's approval for scheduled treatments. The resident reported feeling congested and experiencing breathing difficulties due to the lack of consistent treatment. The facility's policy required that orders be entered electronically by the practitioner or, in certain circumstances, by the nursing staff. However, due to computer issues and oversight, the order was not updated, and the medication was not administered as required. Interviews with facility staff, including a Certified Medication Tech (CMT), a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the Administrator, revealed a breakdown in communication and procedure. The LPN attempted to update the order but faced technical difficulties, and the change was not saved. The DON and Administrator acknowledged the failure to ensure the order was correctly entered and verified. This deficiency highlights the importance of accurate transcription and verification of physician orders to ensure residents receive the necessary care.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for a resident with multiple pressure wounds, as evidenced by inconsistent documentation and untimely care planning. The resident, who was at risk for pressure ulcers, developed several pressure injuries, including stage II ulcers on the back and unstageable ulcers on the heels. Despite the presence of these wounds, the facility did not consistently document the condition of all wounds, nor did they update the care plan in a timely manner to address the new wounds. The resident's medical records revealed a lack of thorough documentation and assessment of the pressure ulcers. For instance, the nurse's notes and bath sheets often failed to specify the location and condition of the wounds. Additionally, the care plan was not updated to include the back wounds, even though they were identified as early as 10/28/24. This lack of documentation and care planning contributed to the deterioration of the resident's condition, as the wounds worsened over time without appropriate interventions being implemented. Interviews with staff members highlighted a lack of clarity and communication regarding wound care responsibilities. Floor nurses were responsible for daily wound care, but there was uncertainty about the frequency of assessments by the Wound Care Nurse. Furthermore, there was a delay in escalating concerns about the resident's deteriorating wounds to the Nurse Practitioner or Director of Nursing, which may have delayed necessary changes in treatment. The facility's failure to adhere to its own policies and procedures for pressure ulcer management resulted in inadequate care for the resident.
Inappropriate Use of Sit-to-Stand Lift for Resident with Declining Mobility
Penalty
Summary
The facility failed to ensure an environment as free from accident hazards as possible by continuing to use a sit-to-stand lift for a resident who had experienced two prior falls using the same lift. The resident, who had a history of severe cognitive impairment and was unable to bear weight consistently, was transferred multiple times using the sit-to-stand lift despite showing a decline in their ability to bear weight. The facility's policy required staff to use a decision flow chart to determine the appropriate transfer method, but this was not consistently followed, leading to repeated unsafe transfer attempts. The resident's care plan indicated the need for substantial assistance and the use of a sit-to-stand lift, but it was not updated to reflect the resident's declining condition and the need for a safer transfer method, such as a Hoyer lift. Despite recommendations from nursing staff and a physical therapist to downgrade the transfer method, the care plan remained unchanged, and staff continued to use the sit-to-stand lift. Observations showed that the resident was unable to come to a standing position during multiple transfer attempts, and staff did not consistently use non-slip socks or seek additional assistance, further compromising the resident's safety. Interviews with staff revealed a lack of communication and awareness regarding the resident's transfer needs and condition. Staff were expected to perform transfers with one person, despite the facility's policy encouraging the use of two staff members for safety. The facility's failure to update the care plan and ensure proper communication and adherence to safety protocols resulted in continued use of an inappropriate transfer method, placing the resident at risk for further falls and injuries.
Failure to Provide Standard Respiratory Care for CPAP Equipment
Penalty
Summary
The facility failed to provide respiratory care per standard practice for a resident using a CPAP machine. The resident, who was admitted with a diagnosis of chronic respiratory failure with hypoxia, required the use of a CPAP machine at night. However, the facility did not obtain physician orders for the care and cleaning of the CPAP machine, tubing, or mask. The resident reported that prior to admission, they cleaned their CPAP equipment weekly, but since admission, no cleaning had been performed by the facility staff. Interviews with nursing staff revealed a lack of clarity and consistency regarding the cleaning procedures for the CPAP equipment. A registered nurse was unsure if there were specific physician orders for CPAP care, while a licensed practical nurse acknowledged that nurses should obtain such orders and generally clean the equipment with a solution from the utility room. Another nurse indicated that the night shift should rinse the CPAP canister weekly, but admitted to not cleaning or changing the mask or tubing. The Director of Nursing stated that there should be orders to clean the CPAP equipment daily, highlighting a gap in the facility's adherence to standard respiratory care practices.
Failure to Document Bed Rail Assessment and Consent
Penalty
Summary
The facility failed to document an assessment for the risk of entrapment and obtain informed consent prior to the use of bed rails for a resident. The resident, who was admitted with a diagnosis of acute metabolic acidosis, required supervision for rolling and substantial assistance for moving in bed. Despite the care plan indicating the use of bed rails for assistance in turning and repositioning, there was no documented assessment or informed consent in the resident's medical record. Observations over several days confirmed the presence of bed rails in the upright position on the resident's bed. Interviews with facility staff revealed inconsistencies and a lack of clarity regarding the procedures for bed rail assessments and informed consent. While some staff members mentioned the need for a physician's order and assessments, others were unsure of the requirements. The Maintenance Director, responsible for installing and measuring the bed rails, completed an assessment only after being informed that the rails were already installed. The Director of Nursing and the Administrator acknowledged the need for assessments and informed consent, but these were not completed for the resident in question.
Infection Control Deficiency Due to Poor Hand Hygiene and Equipment Handling
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by staff not adhering to hand hygiene procedures and improper handling of equipment, which could lead to the transmission of infectious agents. Specifically, staff members were observed entering a resident's room without performing hand hygiene, and they did not change gloves or sanitize hands during various stages of resident care. This included handling a catheter drainage bag, assisting the resident with toileting, and performing wound care without appropriate hand hygiene or glove changes. Resident #23, who was at risk for pressure ulcers and had an indwelling catheter, was directly affected by these lapses in infection control practices. The resident's care plan required enhanced barrier precautions due to pressure ulcers on both heels and the use of a Foley catheter. However, staff failed to follow these precautions, as observed during interactions with the resident, including placing the catheter drainage bag on the floor and not sanitizing hands or changing gloves between tasks. Interviews with various staff members, including a CNA/RMT, LPNs, the Wound/Infection Preventionist Nurse, the Director of Nursing, and the Administrator, revealed a general understanding of the facility's hand hygiene and equipment handling policies. Despite this, the observed practices did not align with these policies, indicating a breakdown in adherence to infection control protocols. The staff acknowledged the importance of hand hygiene and proper equipment handling, yet the observed deficiencies highlighted a significant gap between policy and practice.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, specifically in implementing enhanced barrier precautions (EBP) and adhering to proper infection control practices during wound care. The facility's policy on EBP, which was designed to reduce the transmission of multidrug-resistant organisms (MDROs), was not timely implemented. Staff did not follow the standard practice of using gowns and gloves during high-contact resident care activities, such as wound care, which put residents' wounds at risk for contamination. Two residents were directly affected by these deficiencies. The first resident had multiple pressure ulcers, including a stage III sacral ulcer and a stage IV ulcer on the left lower buttock. During wound care, LPNs failed to don isolation gowns, did not change gloves between tasks, and did not sanitize hands appropriately. Additionally, contaminated equipment was not properly disinfected, and clean supplies were not placed on a clean surface, increasing the risk of cross-contamination. The second resident, who had a stage IV pressure ulcer on the left lateral back, also received wound care without the use of isolation gowns. The LPN did not sanitize the overbed table before placing supplies on it and failed to change gloves and sanitize hands between tasks. Interviews with staff, including LPNs and the Director of Nursing, revealed a lack of adherence to infection control protocols and a delay in implementing EBP. The facility had not yet established policies for EBP, and staff were not consistently using gowns and gloves during wound care. The Director of Long-Term Care Nursing Operations acknowledged that EBP protocols should have been in place but were still in progress. The Administrator confirmed that the corporation was working on a policy for EBP, but it had not yet been implemented, leading to the observed deficiencies.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Citizens Memorial Healthcare Facility | 0.7 mi | ★★★★★ | 11 | 0 |
| Big Spring Care Center For Rehab And Healthcare | 14.5 mi | ★★★★★ | 3 | 0 |
| Northwood Hills Care Center | 15.3 mi | ★★★★★ | 0 | 0 |
| Colonial Springs Healthcare Center | 17.4 mi | ★★★★★ | 7 | 0 |
| Buffalo Prairie Center For Rehab And Healthcare | 17.5 mi | ★★★★★ | 17 | 1 |
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