Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Parkside Lutheran Home during CMS and state inspections, most recent first.
Care plans were not revised to match current resident conditions for several residents. One resident with chronic pain lacked pain-related care plan details, another with repeated UTIs had no care plan focus for the infections, and a resident with an ileostomy reversal still had an outdated ostomy entry. Two residents with smoking-related issues also had care plans that did not address their smoking behaviors or restrictions, and an RN confirmed the omissions.
Unsanitary kitchen and improper food storage. The kitchen and freezers had food, dirt, grime, and debris on multiple surfaces, including floors, baseboards, equipment, walls, and storage racks. Employee food was stored with resident food in the walk-in cooler, cold packs for resident use were stored next to food in a freezer, and food items were observed touching the ceiling and exposed to ice buildup and dripping in the freezer. The dietary manager confirmed the kitchen needed thorough cleaning and understood the potential for food contamination.
Failure to identify verbal abuse occurred when a CNA and a resident were involved in a loud disagreement with name calling and swearing. The resident had anxiety, hx of TBI, MDD, and unspecified psychosis, and the CNA admitted she argued back instead of walking away. An admin nurse said the incident was not reported to the State because they were separated, though she later agreed the CNA's behavior met the definition of verbal abuse.
Failure to report verbal abuse allegation: A resident and a CNA were involved in a loud disagreement with name calling and swearing in the dining room. Staff heard hollering and banging, removed the resident from the area, and the charge nurse spoke with the CNA, who said she argued back after the resident became upset and used an explicit racial slur. An administrative nurse later stated the incident was not reported to the state, and the facility did not recognize the event as verbal abuse requiring SSA notification.
Failure to investigate verbal abuse involving a resident and a CNA: staff heard a loud disagreement with name calling and swearing in the dining room, and the resident was removed upset after the exchange. The CNA said the resident used horrible names and an explicit racial slur, but the facility did not recognize the event as verbal abuse or fully investigate by interviewing other staff and residents present.
A resident with a PEG tube had a morphine order for buccal use or via PEG tube, but the MAR was transcribed as buccal only. During med pass, an RN administered the morphine through the PEG tube, which did not match the MAR entry. An administrative nurse confirmed the order was not accurately transcribed.
Missing Weekly Wound Assessments for Pressure Ulcer: A resident with a Stage 3 pressure injury to the right heel did not have weekly wound assessments with measurements documented in the medical record, despite facility policy requiring wound assessments upon admission, weekly, and as needed. Wound clinic records showed the heel wound increased in size, and an administrative nurse confirmed the weekly assessments were missing and expected per policy.
Failure to provide timely toileting was identified for a resident with stroke and Alzheimer’s disease who needed substantial/maximal assistance with toileting and was frequently incontinent of urine. Records showed repeated toileting gaps of 3+ hours, including two 8-hour gaps, and surveyors observed urine odor in the room. During one observation, a CNA assisted the resident to the toilet while the resident’s pants were wet and smelled of urine and feces, then transferred the resident to a visibly wet recliner.
Failure to follow EBP and hand hygiene standards affected two residents with orders for barrier precautions. CNAs assisted one resident with toileting and a mechanical lift transfer without gowns, and another CNA assisted a resident with toileting, handled soiled items in the hallway, and exited the room without proper hand hygiene; a nurse also administered PEG tube medication without a gown.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling devices, such as feeding tubes and urinary catheters, and did not make PPE readily available. Additionally, staff did not consistently follow catheter care and hand hygiene protocols, as observed with a resident's urinary drainage bag being placed on the floor and CNAs not sanitizing hands after providing care. These actions violated the facility's infection control policies.
The facility failed to ensure call lights were within reach for a resident with Alzheimer's and mobility issues, risking falls and injury. A resident expressed concerns about staff interactions, and an observation confirmed the call light was out of reach while the resident needed assistance. An administrative nurse acknowledged the expectation for staff to keep call lights accessible.
A facility failed to provide a written notice of transfer to a resident or their representative when the resident was transferred to a hospital. The medical record lacked documentation of the notice, and an administrative staff member confirmed that providing such notice is expected when a resident is hospitalized.
A facility failed to provide a written bed hold notice to a resident or their representative during a hospital transfer. The deficiency was identified through a review of medical records and staff interviews, revealing a lack of documentation for the notice. An administrative staff member confirmed the expectation for staff to issue a bed hold notice whenever a resident is out overnight.
The facility failed to update care plans for three residents to reflect their current medication use, including a diuretic, an anticoagulant, and an antidepressant, as identified through record reviews and staff interviews.
A facility failed to follow professional standards by not transcribing a physician's order for a resident's foley catheter after the resident returned from the hospital. The omission was confirmed by an administrative nurse, who acknowledged that the order was missed during transcription.
The facility failed to properly use gait belts during stand-pivot transfers, as observed with two residents requiring assistance. One resident, with Alzheimer's and a history of femur fracture, was assisted by a CNA who pulled upward on her pants instead of using the gait belt correctly. Another resident, with severe vascular dementia and mobility issues, was similarly assisted by two CNAs. The facility's policy mandates the use of gait belts for safe transfers.
A facility failed to assess a resident with PTSD and identify known triggers, which are essential for trauma-informed care. The resident's medical record lacked an assessment of past traumas, and the care plan did not include known triggers or interventions to prevent re-traumatization. An administrative nurse confirmed the staff's failure to assess and implement necessary interventions. Additionally, the facility could not provide a policy addressing PTSD.
A facility failed to conduct the required Abnormal Involuntary Movement Scale (AIMS) screenings for a resident receiving the antipsychotic medication Abilify, as per their policy. The policy requires AIMS screenings every six months to monitor for tardive dyskinesia, but the resident's medical record lacked the necessary reassessments. An administrative nurse confirmed the expectation for biannual reassessments, highlighting a lapse in adherence to the facility's guidelines.
Care plans not updated to reflect resident status
Penalty
Summary
The facility failed to review and revise care plans to reflect current resident status for 5 of 12 sampled residents. Review of the facility policy stated that each resident's comprehensive care plan should incorporate identified problem areas, risk factors, treatment goals, objectives, and be revised as resident assessments and conditions change. The facility also had a smoking policy stating smoking-related privileges, restrictions, and concerns shall be noted on the care plan. Resident #2 had diagnoses including atypical facial pain, low back pain, polyosteoarthritis, and generalized abdominal pain, and the admission MDS indicated moderate and frequent pain, but the care plan did not include pain management problems, goals, or interventions. Resident #4 had multiple UTIs documented over time, but the care plan did not address chronic urinary tract infections. Resident #5 had left hip pain and other chronic pain, with an MDS indicating pain almost constantly and orders for acetaminophen, gabapentin, and Advil PRN, but the care plan did not address pain management or smoking-related behaviors despite notes that the resident was not returning cigarettes to the nurse after smoking. Resident #8 had tobacco use and a smoking assessment stating the resident often did not follow smoking rules or return smoking materials to the nurse, but the care plan did not address those behaviors. Resident #41 had an ileostomy diagnosis, but after a hospital stay and ileostomy reversal, the care plan still identified a colostomy and did not reflect the reversal. An administrative nurse confirmed the care plans were not updated.
Unsanitary kitchen and improper food storage
Penalty
Summary
The facility failed to ensure safe food practices and failed to maintain a clean and sanitary kitchen environment for 1 of 1 kitchen and 2 of 2 freezers on the Cozy Cottage Unit. Review of the 2022 FDA Food Code and facility policy showed food was required to be stored in a clean, dry location and staff foods/fluids were not to be stored in the kitchen refrigerator/freezer. During observation with the dietary manager, the kitchen had an accumulation of food, dirt, grime, and debris on the floor, tiled baseboards, ice machine grate, refrigerator and freezer grates, and large flour and sugar containers. All kitchen walls had splashes of food particles with areas of a sticky yellow substance, and the walk-in cooler had food storage racks with peeling surface material coated with dirt, rust, or grime. Employee food items were stored alongside resident food items in the walk-in cooler. The walk-in freezer had a condenser line with thick ice and frost buildup, and ice droplets formed in front of the ceiling fan, with ice particles dropping onto a package of food under the fan. Cold packs for resident use were stored next to food items in the freezer on the Cozy Cottage Unit. A later observation showed the base of a blender covered with food particles and a sticky substance, two beverage cup carts covered with dirt and debris, and a package of fried steak and a bag of cooked shrimp touching the ceiling in the walk-in freezer. The administrative dietary manager confirmed the kitchen needed thorough cleaning and understood the potential for food contamination.
Failure to Identify Verbal Abuse Involving a Resident
Penalty
Summary
The facility failed to identify and respond to an incident of verbal abuse involving one resident who was subjected to name calling and swearing by a CNA. The resident had diagnoses including anxiety, a history of traumatic brain injury, major depressive disorder, and unspecified psychosis, and his care plan directed staff to observe for signs and symptoms of depression and/or anxiety, document and report concerns to the charge nurse, and offer emotional support. A memo documented that the resident and the CNA were involved in a loud disagreement in the dining room, with hollering, banging, name calling, and swearing going back and forth. Another memo stated the CNA admitted she argued back after the resident became upset, and she acknowledged she should have walked away instead of engaging. An administrative nurse stated the incident was not reported to the State because the resident and staff member were immediately separated, and later conceded the CNA's behavior met the definition of verbal abuse. The resident stated he did not like that CNA.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to immediately report an incident of verbal abuse involving one resident who was subjected to name calling and swearing by a CNA. Review of the facility policy stated that any staff witnessing mistreatment or abuse must immediately notify the charge nurse, who must then immediately notify the Administrator, Social Services Designee and/or DON, and the ND Department of Health must be notified of allegations of abuse with an investigation pending. A memo documented that a writer heard hollering and banging coming from the dining room, where the resident and the CNA were having a loud disagreement with a lot of name calling and swearing going back and forth. The writer removed the resident from the dining room, and the charge nurse visited with the CNA. Another memo stated that during the meeting with the CNA, she said she had glanced at her phone while waiting to serve breakfast, the resident "went off," and she responded by arguing back. She stated that in hindsight she should have walked away and that she knew it was wrong to respond, but the resident was calling her horrible names and using an explicit racial slur. During an interview, an administrative nurse stated she did not report the incident to the state. The facility did not recognize the loud disagreement, name calling, and swearing as verbal abuse and did not report the allegation to the SSA.
Failure to Investigate Verbal Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of verbal abuse involving one sampled resident who was subjected to name calling and swearing by a CNA. A memo documented that a staff member heard hollering and banging coming from the dining room, where the resident and the CNA were having a loud disagreement with a lot of name calling and swearing going back and forth. The resident was removed from the dining room by another staff member, and the charge nurse visited with the CNA. The resident was upset with the CNA and said he wanted coffee, but could not really explain how the situation started. Facility records also showed that during a meeting with the CNA, she stated that while she was waiting to serve breakfast and glanced at her phone, the resident "went off" and began arguing with her. She acknowledged that she should have walked away and not engaged, and said the resident was calling her horrible names and using an explicit racial slur. The facility policy required all allegations to be thoroughly investigated under the direction of the Administrator, including interviewing all persons associated with the situation, but the facility failed to recognize the loud disagreement, name calling, and swearing as verbal abuse and did not thoroughly investigate the incident, including interviewing other staff members and residents who were present in the dining room.
Inaccurate transcription of morphine route for a resident with a PEG tube
Penalty
Summary
Medication was not provided in accordance with professional standards for one resident with a PEG tube. The resident had a physician order dated 12/08/25 for morphine concentrate to be administered buccally or per PEG tube for pain or dyspnea. Review of the December 2025 MAR showed the order was transcribed as buccal only and did not include the PEG tube route. During observation on 12/10/25 at 1:30 p.m., a nurse administered morphine through the resident’s PEG tube, which did not match the route documented on the MAR. An administrative nurse later confirmed that staff failed to accurately transcribe the order in the MAR.
Missing Weekly Wound Assessments for Pressure Ulcer
Penalty
Summary
Failure to provide the necessary treatment and services for a resident with a Stage 3 pressure ulcer to the right heel was identified. Facility policy titled Documentation of Wound Treatments stated that wound assessments are to be documented upon admission, weekly, and as needed, and that a complete wound assessment includes the wound type, stage, measurements, description of wound characteristics, and weekly progress toward healing. Review of the resident’s medical record showed wound clinic assessments of the right heel pressure injury with measurements of 0.4 cm x 0.4 cm on 11/06/25 and 0.8 cm x 1 cm on 12/05/25, but the record lacked weekly wound assessments with measurements. During interviews, an administrative nurse confirmed the record lacked weekly wound assessments and stated staff were expected to complete them per the wound treatment policy.
Failure to Provide Timely Toileting and Clean Transfer Surface
Penalty
Summary
Failure to provide appropriate toileting was identified for one sampled resident who required staff assistance with toileting. The resident had diagnoses of cerebral infarction (stroke) and Alzheimer's disease. The MDS identified substantial/maximal assistance with toileting and that the resident was frequently incontinent of urine and occasionally incontinent of bowel. The care plan stated that the resident needed assistance with toileting, and a nurse's note documented that the resident's urine had a strong odor during toileting cares. Review of the bladder elimination task record for the resident showed toileting gaps of three or more hours each day, including an eight-hour gap on one day and another eight-hour gap on a different day. Observation during the survey found a urine odor in the resident's room on all days. On one observation, a CNA assisted the resident to the toilet and the resident's pants were visibly wet and smelled of urine and feces; the CNA removed the soiled clothing and brief, completed perineal care, applied a new brief and pants, and transferred the resident to a recliner that was visibly wet from urine. An administrative nurse stated that staff were expected to assist residents with toileting every two to three hours and as needed unless independent, replace a wet recliner while the soiled recliner is cleaned, and at least place a barrier between the resident and a wet recliner.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to follow infection control and prevention standards for residents on enhanced barrier precautions (EBP), including hand hygiene and use of gowns during high-contact care. The facility policy stated that EBP is ordered for residents with wounds and/or indwelling medical devices, and that PPE is required for high-contact care activities such as transferring, providing hygiene, changing briefs or assisting with toileting, and device care or use, including feeding tubes. The hand hygiene policy stated that hand hygiene is required before and after resident contact, before and after handling invasive devices, before and after assisting a resident with toileting, and after removing gloves. Resident #2 had a physician order for advanced barrier precautions every shift. During observation, two CNAs performed hand hygiene, applied gloves, and transferred the resident from a wheelchair to the toilet using a mechanical lift and assisted with toileting, but did not apply gowns as required by the EBP policy. Resident #31 had a physician order for enhanced barrier precautions. During observation, a CNA assisted the resident to the toilet with gloves but without a gown, removed soiled gloves after perineal care, then applied clean gloves and handled garbage and dirty clothing bags in the hallway without performing hand hygiene. The CNA later returned to the room, removed gloves, performed hand hygiene, clipped the call light to the resident's sweatshirt sleeve, plugged the power cord back into the tube feeding device, and exited without performing hand hygiene. A nurse also entered the resident's room and administered medication through the PEG tube without applying a gown. An administrative nurse stated that staff were expected to perform hand hygiene and wear gowns and gloves for residents on EBP during close contact care and medication administration through a PEG tube.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for several residents, particularly in the application of Enhanced Barrier Precautions (EBP). Resident #11, who had multiple wounds requiring dressing changes, was not placed on EBP, and personal protective equipment (PPE) was not made readily available to staff. Similarly, Resident #90, with a feeding tube, and Resident #139, with a urinary catheter, were not placed on EBP, and PPE was not accessible, despite the facility's policy requiring such measures for residents with indwelling medical devices. In addition to the lack of EBP, the facility's staff did not consistently follow proper catheter care and hand hygiene protocols. Observations revealed that CNAs handling Resident #139's urinary drainage bag failed to keep it off the floor and did not perform hand hygiene after handling soiled equipment. The CNA also reconnected the drainage tube without sanitizing it after it had been dropped on the floor. These actions were contrary to the facility's policies on catheter care and hand hygiene. Further deficiencies were noted in hand hygiene practices during resident care. CNAs assisting Residents #14 and #25 with toileting and peri-care did not perform hand hygiene after removing gloves and before proceeding with other tasks. This failure to sanitize hands after providing care and before exiting the room or performing additional tasks was a direct violation of the facility's hand hygiene policy, which emphasizes hand hygiene as a primary means of preventing infection transmission.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure care and services were provided according to accepted standards of quality for a resident observed during stand-pivot transfers. Specifically, the staff did not place call lights within the resident's reach, which placed residents at risk for falls and/or injury. During interviews, a resident expressed concerns about the staff's interaction with her roommate, who frequently asked to go to the bathroom but often found the call light out of reach. An observation confirmed that the resident was sitting in her wheelchair with the call light attached to the bed, out of reach, while she expressed a need to use the bathroom. The resident's medical record indicated diagnoses of Alzheimer's disease, dementia, osteoarthritis, and a history of left femur fracture, with a care plan requiring assistance for locomotion and transfers. An administrative nurse confirmed the expectation that staff should ensure call lights are within reach of residents.
Failure to Provide Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident or their representative, which is a requirement when a resident is transferred to a hospital. This deficiency was identified during a review of the medical records for a resident who was transferred to a hospital. The medical record did not contain documentation that the facility had provided the necessary written notice of transfer. An administrative staff member confirmed during an interview that it is expected for staff to provide such notice whenever a resident is hospitalized.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written notice of bed hold to a resident or their representative during a hospital transfer. This deficiency was identified during a review of the medical records and staff interviews. Specifically, the medical record of a resident who was transferred to a hospital lacked documentation that a written bed hold notice was provided. An administrative staff member confirmed that it is expected for staff to provide such a notice whenever a resident is out of the facility overnight.
Failure to Update Care Plans for Medication Use
Penalty
Summary
The facility failed to review and revise the comprehensive care plans to reflect the current status for three residents. Resident #5's care plan did not address the use of a diuretic medication, despite the quarterly Minimum Data Set (MDS) and current physician's orders indicating that the resident received Lasix daily. Similarly, Resident #7's care plan failed to include the use of an anticoagulant medication, even though the MDS and physician's orders showed that the resident was on Eliquis daily. Additionally, Resident #30's care plan did not reflect the use of an antidepressant medication, despite the MDS and physician's orders indicating daily administration of Mirtazapine. These omissions in the care plans were identified through observation, record review, and staff interviews, highlighting a failure in the facility's process to ensure that care plans are updated to communicate residents' current medication needs effectively.
Failure to Transcribe Physician's Order for Catheter
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding physician's orders for a resident with a catheter. During the survey, it was observed that the resident had a catheter bag under her wheelchair. Upon reviewing the resident's medical record, it was found that after returning from the hospital, the current physician's orders did not include an order for the resident's foley catheter. An administrative nurse confirmed that the staff failed to enter the order for the catheter, indicating that the order was missed during transcription when the resident returned from the hospital.
Failure to Properly Utilize Gait Belts During Transfers
Penalty
Summary
The facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury during stand-pivot transfers for one of the sampled residents. Observations revealed that a certified nurse aide (CNA) placed a gait belt around a resident's waist, tightened it, locked the brakes on the wheelchair, and assisted the resident to stand by pulling upward on the back of her pants. This action was contrary to the facility's policy, which mandates the use of a gait belt for all residents requiring assistance with transfers and ambulation to ensure safety from injury. The resident involved had a medical history that included Alzheimer's disease, dementia, osteoarthritis, and a history of left femur fracture, and required assistance with transfers as identified in her care plan. Another observation showed two CNAs assisting another resident with toileting, where one CNA placed a gait belt around the resident's waist and assisted her to stand by pulling upward on the back of her pants. This resident had diagnoses including abnormalities of gait/mobility, disorders of bone density/structure, right hemiplegia following a cerebral infarction, and severe vascular dementia, and also required assistance with transfers. An administrative nurse confirmed that staff were expected to utilize a gait belt when transferring residents.
Failure to Assess PTSD and Identify Triggers
Penalty
Summary
The facility failed to assess a resident with a history of Post-Traumatic Stress Disorder (PTSD) and identify known triggers, which is crucial for providing trauma-informed care. The medical record of the resident, who has a complex psychiatric history including PTSD, lacked an assessment addressing past traumas. Additionally, the care plan did not identify known triggers or list interventions to prevent re-traumatization. An administrative nurse confirmed that staff did not assess residents with PTSD, identify their known triggers, or implement interventions to prevent re-traumatization. Furthermore, the facility was unable to provide a policy addressing PTSD.
Failure to Conduct Required AIMS Screenings for Antipsychotic Medication
Penalty
Summary
The facility failed to manage and monitor a resident's drug regimen effectively, which is necessary to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility did not complete the required Abnormal Involuntary Movement Scale (AIMS) screenings for a resident receiving the antipsychotic medication Abilify, which is used to treat major depression and psychosis. The facility's policy mandates that AIMS screenings be conducted every six months for residents on neuroleptic medications to assess for tardive dyskinesia, an involuntary movement disorder. However, the medical record for the resident in question did not include the necessary reassessments for January 2024 and July 2024. During the survey, it was confirmed by an administrative nurse that the expectation was for staff to reassess any resident receiving antipsychotic medication every six months. Despite this policy, the facility failed to adhere to its own guidelines, as evidenced by the absence of the required AIMS screenings in the resident's medical record. This oversight could potentially lead to adverse reactions to the medication, such as tardive dyskinesia, although the report does not specify any such outcomes for the resident involved.
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Illustrative
What surveyors actually found near you
We read the 15 citations issued within 25 miles in the last 12 months — 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
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Illustrative
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How nearby facilities compare on the same public inspection record.
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|---|---|---|---|---|
| North Dakota Veterans Home | 2.6 mi | ★★★★★ | 0 | 0 |
| Smp Health - Maryhill | 13.4 mi | ★★★★★ | 3 | 0 |
| Four Seasons Health Care Inc | 23.6 mi | ★★★★★ | 12 | 0 |
| Good Samaritan Society - Oakes | 28.2 mi | ★★★★★ | 11 | 1 |
| St Rose Care Center | 29.4 mi | ★★★★★ | 12 | 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.