Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident at high risk for pressure ulcers developed stage IV wounds on both inner elbows after staff failed to promptly document and treat open areas first identified by a CNA. Despite care plans and regular skin checks, the wounds were not addressed until they had progressed significantly, with staff interviews confirming delays in communication and intervention.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not maintain hot water tank temperatures at the required 140°F for the kitchen and all nursing units, with observed temperatures ranging from 118°F to 122°F. Weekly temperature monitoring was not completed as outlined in the Legionella Water Management Plan, and staff confirmed these lapses, potentially affecting all residents.
The facility did not ensure that two CNAs completed the required 12 hours of annual continuing education, with both having only five hours documented for the year. This lapse was confirmed by the HRM and had the potential to impact all residents in the facility.
Two residents experienced unsanitary conditions in a shared room, including a persistent urine odor and a sticky, soiled floor due to staff not emptying a urinal, resulting in urine spillage. Additional issues were found in shower rooms, such as missing toilets, exposed pipes, dark discoloration between tiles, and improperly fitted toilet seats, all confirmed by staff interviews.
The facility did not hold regular care conferences for several residents with complex medical needs, resulting in missed opportunities for residents and their representatives to participate in care planning as required by facility policy. This deficiency was confirmed through medical record review, interviews, and care conference documentation.
A resident with impaired cognition and multiple medical conditions was moved to a different room without written notification to the resident or their representative, as required by facility policy. Staff interviews confirmed the representative was only informed after the move had already taken place.
Staff left a respiratory therapy cart unattended with an open computer monitor displaying a resident's private health information, resulting in a failure to maintain EMR privacy as required by facility policy. The incident involved a resident with severe cognitive impairment and multiple medical conditions, and was confirmed by the ADON.
A resident with a history of acute respiratory failure, mechanical ventilation, and tracheostomy was decannulated following a physician's order, but the facility did not complete a comprehensive MDS assessment within 14 days of this significant change in condition, as confirmed by staff interview and medical record review.
A resident admitted with anoxic brain damage and post-traumatic seizures did not receive a baseline care plan summary within 48 hours of admission, despite having intact cognition and requiring staff assistance with ADLs. Interviews confirmed the resident was not informed about his care plan, and facility policy requiring resident participation and documentation was not followed.
A resident with multiple chronic conditions and impaired cognition developed an open wound behind the ear, which was identified by nursing staff but not treated according to physician orders. Despite ongoing observations of blood-stained bedding and staff awareness of the wound, no specific treatment was initiated, and the wound persisted with drainage.
A resident with multiple serious diagnoses was readmitted after a hospital stay and reported pain, receiving one dose of oxycodone based on an outdated order. After this, the resident continued to experience pain but did not receive further pain medication because staff did not have a current physician order, despite repeated complaints. Staff interviews confirmed the lapse, and facility policy required pain assessment and management at admission and with changes in condition.
Two residents receiving insulin had their insulin pens placed in the medication cart without being dated when removed from refrigeration, as confirmed by an LPN and facility nursing leadership. This failure to label insulin pens was observed during a review of medication storage practices and was not in accordance with manufacturer guidelines or facility policy.
Four resident rooms were found without privacy curtains, preventing residents from having full visual privacy during personal care. Staff confirmed the absence of proper privacy curtains, which did not align with the facility's policy on resident rights to privacy.
A resident with significant neurological diagnoses had her hair cut by staff without her consent, despite her explicit request to stop the procedure midway. Staff continued the haircut after encouragement, citing permission from the resident's POA due to matted hair. Facility policy affirms the resident's right to refuse care, but this right was not upheld during the incident.
Two residents reported receiving food that was consistently cold, unappealing, and sometimes contaminated, with one meal containing a gnat. Dietary staff were observed not following recipes and preparing mechanical soft and pureed foods in an unappetizing manner. Meals were left on carts for extended periods, resulting in cold and unpleasant food, as confirmed by both residents and staff.
The facility did not maintain an effective pest control program, as evidenced by multiple incidents where residents with impaired cognition and various medical conditions were exposed to pests such as large flying insects, gnats in meal containers, and flies on mobility equipment. These issues were confirmed by staff observations and interviews, and maintenance staff were not always aware of the pest problems.
Failure to Timely Identify and Treat Pressure Ulcers Resulting in Stage IV Wounds
Penalty
Summary
A deficiency occurred when the facility failed to implement timely treatment for pressure ulcers after they were identified in a resident who was admitted without pressure ulcers but was at high risk for their development. The resident, who had chronic respiratory failure, encephalopathy, epilepsy, and was in a persistent vegetative state, was dependent on staff for all activities of daily living and received tube feeding. Despite care plans and physician orders for regular skin checks and preventative interventions, the resident developed pressure ulcers on both antecubital spaces (inner elbows), which were not documented or treated promptly. Certified Nursing Assistant (CNA) identified open areas on the resident's inner elbows during a shower and reported them to the nurse on duty. However, there was no documentation of these open areas in the medical record for several days, and no treatment was initiated until nearly a week later, by which time the wounds had progressed to stage IV pressure ulcers with exposed tendon. Weekly skin checks conducted prior to this did not note any open areas, and the facility's policy required immediate assessment and documentation by licensed nurses upon identification of new pressure injuries. Interviews with staff revealed a lack of timely communication and follow-up after the CNA's report, with the wound nurse unable to recall when she was notified. The Director of Nursing acknowledged the resident's compromised condition but confirmed that timely treatment was not obtained. The facility's failure to act promptly on the initial identification of skin breakdown led to the development of severe pressure ulcers, as confirmed by subsequent wound assessments and observations.
Failure to Follow Professional Standards for Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events leading to the deficiency are provided in the report.
Failure to Maintain and Monitor Hot Water Tank Temperatures per Legionella Plan
Penalty
Summary
The facility failed to implement and maintain its Legionella Water Management Plan as required. Review of the plan revealed that hot water tanks supplying the nursing units and kitchen were to be maintained at a minimum of 140 degrees Fahrenheit, with weekly monitoring of flow and return temperatures. However, observations showed that the kitchen hot water tank reached only 122 degrees Fahrenheit, and the tanks for the 100, 200, 300, and 400-nursing units reached only 118 degrees Fahrenheit. Maintenance staff confirmed these temperatures did not meet the required threshold, and also verified that weekly temperature monitoring had not been completed for any of the tanks. Interviews with facility staff, including the Senior Administrator, confirmed the expectation that all hot water holding tanks should be maintained at or above 140 degrees Fahrenheit. The facility's Legionella Water Management Plan mission statement emphasized the importance of proactive steps to prevent Legionnaires' disease through proper water system management. Despite this, the facility did not adhere to its own protocols for temperature maintenance and monitoring, potentially affecting all 67 residents in the facility.
Failure to Ensure Required CNA Continuing Education
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed the required annual continuing education hours. Specifically, a review of personnel files showed that one CNA, hired in December 2022, had completed only five hours of continuing education for the 2024 calendar year, and another CNA, hired in February 2023, also had only five hours completed for the same period. Interviews with the Human Resources Manager confirmed that both CNAs had not met the required 12 hours of annual continuing education. This deficiency had the potential to affect all 67 residents in the facility, as it involved non-compliance with mandated training requirements for CNAs.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment for its residents, as evidenced by multiple observations and interviews. In one shared room, a strong urine odor and a dirty, sticky floor were noted. One resident reported dissatisfaction with staff for not emptying his roommate's urinal, which would overflow and cause urine to spill onto the floor and under the curtain to his side of the room. A Licensed Practical Nurse confirmed the presence of a strong urine odor and soiled, sticky flooring in the area near the urinal. Both residents in the room had significant medical conditions, with one requiring staff assistance for activities of daily living and the other requiring supervision. Additional deficiencies were observed in the facility's shower rooms. In one shower room, the toilet was missing, the pipe was covered, and there were missing tiles around the pipe. In another shower room, there was dark discoloration between the shower tiles, a toilet seat that did not fit the bowl properly, and missing tiles at the entrance exposing rough, jagged flooring. These findings were confirmed by facility staff, including a floor technician and a registered nurse. The facility's own policy required maintaining a homelike, sanitary, and comfortable environment, including prompt disposal of soiled linens and addressing lingering odors.
Failure to Hold Regular Resident Care Conferences
Penalty
Summary
The facility failed to conduct regular care conferences for multiple residents, as required by their own policy and federal regulations. Medical record reviews, resident and staff interviews, and care conference summary reports revealed that care conferences were not held for five residents across several quarters. These residents had significant medical conditions, including chronic respiratory failure, morbid obesity, diabetes mellitus, quadriplegia, encephalopathy, epilepsy, and dependence on mechanical ventilation. Despite having intact or impaired cognition and being dependent on staff for activities of daily living, these residents and their representatives were not included in care planning discussions at the required intervals. Interviews with the Social Services Director and Regional Social Services Director confirmed that care conferences were missed for each resident during specific quarters, sometimes spanning multiple consecutive quarters. The facility's policy stated that residents and/or their representatives should be informed of and participate in care planning at regularly scheduled conferences, with documentation of their participation. However, the lack of these conferences meant that residents and their representatives were not given the opportunity to participate in or be informed about their care plans as required.
Failure to Notify Resident and Representative of Room Change
Penalty
Summary
The facility failed to notify a resident and the resident's representative in writing of a room change, as required by facility policy. Medical record review showed that the resident, who had impaired cognition and multiple diagnoses including hypoxic ischemic encephalopathy, cerebral infarction, CHF, hypertension, and schizoaffective disorder, was dependent on staff for medication administration, transfers, eating, and personal care. Progress notes did not document the room change, and interviews with the resident's representative and the Admissions Director confirmed that the representative was not informed of the move until after it had occurred. Facility policy required written notification in a language and manner understandable to the resident and representative, including the reason for the move, but this was not followed.
Failure to Protect Resident EMR Privacy
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of a resident's electronic medical record (EMR) as required by facility policy. During an observation, a respiratory therapy treatment cart was found unattended on the 400-nursing unit with an open computer monitor displaying private health information belonging to a resident who had severe cognitive impairment and was dependent on staff for activities of daily living. The Assistant Director of Nursing confirmed that staff did not protect the resident's medical information. The facility's policy states that only appropriate employees should have access to electronic protected health information and that reasonable measures must be implemented to safeguard resident records.
Failure to Complete Comprehensive Assessment After Significant Change
Penalty
Summary
The facility failed to conduct a comprehensive assessment within 14 days following a significant change in condition for one resident. The resident, who had diagnoses including acute respiratory failure with hypoxia, mechanical ventilation dependence, tracheostomy, and cerebral infarction, was admitted on 08/23/24. The quarterly Minimum Data Set (MDS) assessment indicated the resident had intact cognition and was dependent on staff for activities of daily living. On 07/09/25, the resident was decannulated following a physician's order, as documented by the respiratory therapist. However, a review of the medical record showed that a comprehensive MDS assessment was not completed after this significant change in the resident's status. This was confirmed by the Regional MDS Nurse during an interview.
Failure to Provide Baseline Care Plan Summary Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete and provide a baseline care plan summary to a resident within 48 hours of admission, as required by policy. Medical record review showed that the resident, admitted with diagnoses including anoxic brain damage and post-traumatic seizures, did not receive a summary of the baseline care plan upon admission. The Minimum Data Set (MDS) assessment indicated the resident had intact cognition and required staff assistance with activities of daily living (ADLs). Interviews with the resident and the Social Services Director confirmed that the resident was not provided with a summary of the baseline care plan and could not recall any meeting regarding his care. Facility policy requires that residents be informed of and participate in their care planning, with documentation of the discussion or viewing of the care plan. This process was not followed for the resident in question.
Failure to Initiate Treatment for Non-Pressure Wound
Penalty
Summary
The facility failed to identify and initiate prompt treatment for a non-pressure wound in a resident with multiple complex medical conditions, including hypoxic ischemic encephalopathy, cerebral infarction, congestive heart failure, schizoaffective disorder, and hidradenitis suppurativa. The resident, who was cognitively impaired and dependent on staff for activities of daily living, was admitted with these diagnoses. On review, a nurse identified blood on the resident's pillow and an open wound behind the right ear, initially applying A&D ointment. However, subsequent progress notes and the Treatment Administration Record showed no specific treatment orders for the wound, and the wound persisted with ongoing drainage and staining of the resident's pillow. Multiple observations and staff interviews confirmed the presence of the open wound and the lack of a treatment plan. Housekeeping staff noted dried blood stains on the resident's pillow, and both the resident's representative and a CNA acknowledged the wound had been present for several weeks. An LPN confirmed the wound was identified but not treated, and the nurse practitioner clarified that while there was an order for ointment for dry skin, there was no order specific to the wound behind the ear. The Assistant Director of Nursing also confirmed that no treatment was initiated after the wound was first identified.
Failure to Appropriately Assess and Manage Pain After Readmission
Penalty
Summary
A resident with a history of traumatic subdural hemorrhage, cerebral infarction, heart failure, and spinal stenosis was readmitted to the facility following a hospital stay. Upon readmission, the resident reported pain and rated it as a three out of ten. The resident received a dose of oxycodone 5 mg on the evening of readmission, based on a previous order that was no longer valid, as the hospital discharge orders did not include oxycodone. Subsequent to this dose, the resident continued to report pain but did not receive further pain medication because there was no current physician order for it on file. Staff interviews confirmed that the resident repeatedly voiced complaints of pain, but no additional pain medication was administered after the initial dose due to the lack of a valid order. The facility's pain management policy required assessment and management of pain consistent with professional standards and the resident's care plan, including upon admission and significant changes in condition. The failure to obtain a new order and provide appropriate pain management resulted in the resident experiencing untreated pain following readmission.
Failure to Label Insulin Pens Upon Removal from Refrigeration
Penalty
Summary
Facility staff failed to ensure that insulin pens for two residents were properly labeled when removed from refrigerated storage and placed in the medication cart. For one resident with severe cognitive impairment and diabetes mellitus, the insulin Glargine pen was observed on the medication cart without a date label. The LPN confirmed that the pen was not dated at the time it was moved from refrigeration. Similarly, another resident with diabetes mellitus and other chronic conditions had a Lantus SoloStar insulin pen in the medication cart that was also not dated, as confirmed by the LPN. Interviews with the Director of Nursing and Assistant Director of Nursing verified that insulin is required to be dated when removed from refrigeration and placed in the medication cart. Review of the manufacturer's guidelines and facility policy indicated that medications, including insulin, should be labeled with the date when taken from refrigeration. The observations and staff confirmations demonstrated that the facility did not follow these labeling requirements for insulin storage for the two affected residents.
Lack of Privacy Curtains in Resident Rooms
Penalty
Summary
During an observation conducted with the Assistant Director of Nursing, it was found that four resident rooms did not have privacy curtains installed, preventing residents from having full visual privacy when needed. Staff confirmed that the facility had not provided proper privacy curtains in these rooms. Review of the facility's Resident Rights policy indicated that residents are entitled to privacy during personal care, but this standard was not met for the affected residents.
Resident's Right to Refuse Care Not Honored During Haircut
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's right to refuse a haircut. The resident, who had a history of traumatic subarachnoid hemorrhage, hydrocephalus, anoxic brain damage, and epilepsy, was admitted to the facility and later had her hair cut by staff without her consent. On the day of the incident, the resident was brought to the nurses' station, and staff began cutting her hair. The resident explicitly asked the staff to stop the haircut halfway through, but the staff did not comply with her request and continued to cut her hair. Interviews with staff confirmed that the haircut was completed despite the resident's refusal, and that encouragement was given to continue the haircut since it was already partially done. The resident's power of attorney had given permission for the haircut, believing it was necessary due to the resident's hair being matted. However, the facility's policy states that residents have the right to request, refuse, and discontinue treatment, as well as make choices about aspects of their life that are significant to them. The incident was later reported and investigated as a potential case of neglect or mistreatment, but the facility did not substantiate abuse. Documentation and interviews confirmed that the resident's rights were not honored during this event.
Unpalatable and Improperly Served Food Provided to Residents
Penalty
Summary
The facility failed to provide residents with food that was appealing, palatable, and served at a safe and appetizing temperature. Observations and interviews revealed that one resident with multiple diagnoses, including vascular dementia and heart failure, received a mechanical soft meal that was cold, tasted unpleasant, and contained a gnat. The resident confirmed the food was consistently cold and unpalatable. An LPN also confirmed the meal was unappealing and contaminated. Another resident, cognitively intact and requiring set-up assistance, reported dissatisfaction with the food, stating it was unappealing and never served at the correct temperature, attributing this to food trays sitting on carts for extended periods before distribution. Further observations in the kitchen showed improper preparation of mechanical soft and pureed foods, with dietary staff not following recipes and instead relying on estimation. The mechanical soft fish was prepared into an unappealing lump, and the dietary staff themselves stated they would not eat it. The broccoli was prepared with excessive water and thickener to achieve a mashed potato texture. A test tray left the kitchen and sat for 20 minutes before being served, resulting in cold, chewy, and unappetizing food items, including fish, broccoli, rice casserole, and cake. The dietary manager confirmed the test tray was unappealing, with cold and chewy food and dry, hard cake.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple incidents involving three residents. In one case, a resident with a history of atherosclerotic heart disease, osteoarthritis, and asthma, and who had impaired cognition, was observed to have multiple large black flying insects in their room. This observation was confirmed by the unit manager. In another instance, a resident with chronic atrial fibrillation, major depressive disorder, vascular dementia, and anorexia, also with impaired cognition, was found to have a gnat flying inside their meal container. This was confirmed by both the resident and an LPN, who noted the meal tray was unappealing due to the presence of the gnat. Maintenance staff reported that pest issues were to be communicated to the pest control company when notified by staff. Additionally, a third resident with anemia, congestive heart failure, hypertension, and diabetes mellitus was observed to have multiple flies on their motorized wheelchair. The presence of flies in the resident's room was verified by an LPN, but maintenance staff were not aware of this issue. Review of the facility's pest control policy indicated that the facility was responsible for eradicating and containing common household pests, but the observed incidents demonstrated a failure to implement this policy effectively.
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What surveyors actually found near you
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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 Fairfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Fairfield Llc | 1.5 mi | ★★★★★ | 0 | 0 |
| Hamilton Respiratory And Nursing Center | 2.4 mi | ★★★★★ | 14 | 0 |
| Residence At Huntington Court | 2.6 mi | ★★★★★ | 2 | 0 |
| Glen Meadows | 3 mi | ★★★★★ | 4 | 0 |
| Veranda Gardens Nursing & Rehabilitation Center | 3.8 mi | ★★★★★ | 6 | 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.