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 Parkview Manor Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with COPD, paraplegia, depression, dementia, and nicotine dependence, who was cognitively intact per BIMS, experienced ongoing verbal and emotional abuse and intimidation by an LVN. Documentation and interviews showed the LVN told the resident to get off her hall and not return, while the resident reported the LVN had popped her in the mouth. The resident and staff reported that the LVN spoke rudely to the resident, refused to take her on smoke breaks while taking other smoking residents, restricted her from approaching the nurse’s station, grabbed and turned her motor wheelchair away from the area, and prompted the removal of the resident’s cigarettes from the nurse’s station. The resident altered her routes within the facility to avoid the LVN and initially felt bad and sad about being excluded from smoke breaks. Despite these reports and observations, the facility did not update the resident’s care plan to reflect the abuse allegations or recognize the pattern of verbal and emotional abuse and intimidation.
A resident with dementia, multiple chronic conditions, and impaired communication was transferred to a hospital for stroke-like symptoms, but the responsible LVN did not complete required change-of-condition and discharge documentation. Family reported they were not officially notified by the facility of the resident’s change in condition or transfer, and staff interviews confirmed there were no timely clinical notes detailing the reason for transfer, physician and family contacts, or how and when the resident left. The interim DON and ADM stated that the absence of an SBAR prevented the discharge summary from being generated and kept the discharge from appearing on the ADT report until a discharge summary was completed later after surveyor intervention.
A resident with paraplegia, COPD, dementia, major depressive disorder, and other psychiatric conditions, and with intact cognition per BIMS, alleged that an LVN struck her in the mouth following earlier documented verbal conflicts and agitation between them. Nursing notes described the resident’s verbal outbursts and an evening hallway argument where the LVN yelled at the resident and told her to leave the hall, with no immediate injuries or distress noted. After the resident later reported being "popped" in the mouth, the DON completed a physical assessment and notified the responsible party and MD, but the facility did not conduct a psychosocial assessment or risk assessment, and the resident’s care plan was never updated to reflect the abuse allegation, resulting in a failure to ensure necessary psychosocial care and services.
A resident with dementia, muscle wasting, gait abnormalities, and impaired cognition experienced a significant change in condition with stroke-like symptoms that led to an emergency hospital transfer. Family members reported they were not promptly informed of the resident’s worsening condition or discharge, and staff accounts described concerns raised by a family member, a med aide’s difficulty administering medications when the resident was unusually sleepy, and an elevated BP that prompted an LVN to call 911. Despite this, the resident’s clinical record lacked an SBAR/change-of-condition report, timely nursing progress notes, and a contemporaneous discharge summary documenting assessment findings, vital signs, notifications to the MD and family, and the rationale for transfer. The interim DON and administrator confirmed that the required documentation was not completed by the responsible LVN and that the discharge was not properly reviewed, resulting in incomplete and inaccurate medical records related to the resident’s change in condition and hospital transfer.
Surveyors found black, moldlike substances on ceiling tiles in multiple areas, with staff interviews revealing that maintenance had lapsed after the previous director left. An LPN and anonymous staff described ongoing mold issues linked to leaking A/C systems and inadequate repairs, including covering up mold with paint. The facility lacked a policy on physical environment, and the administrator questioned the identification of mold when shown evidence.
A resident with severe cognitive impairment was physically abused by a staff member in an LTC facility. The resident, who was agitated and confused, hit a medication aide (MA) during care, and the MA reacted by hitting the resident back. This incident was witnessed by an LVN and involved a CNA. The resident's care plan advised against unnecessary physical contact due to a history of trauma, but this was not followed. The staff had prior training on abuse and neglect, yet the incident occurred, indicating a failure in applying this training.
The facility failed to ensure a safe, clean, and homelike environment in two shower rooms. Observations revealed soap scum, hard water stains, and a reddish substance in the first shower room, while the second had a missing tile, mildew, and high water temperature. Despite cleaning efforts, stains persisted, and the facility lacked water temperature logs. No residents were reported injured.
The facility did not maintain sufficient RN staffing on several weekends in Q2 2024 due to its remote location, leading to a lack of coverage on specific dates. This shortage was acknowledged by the DON and attributed to difficulties in attracting weekend RNs. The facility's policy requires 24/7 RN or LPN coverage, which was not met.
The facility failed to properly label opened food items in the refrigerator and stored a dented can of tomatoes with other canned goods, contrary to professional standards. This oversight was acknowledged by the Dietary Manager and poses a risk for foodborne illness.
The facility failed to maintain appropriate water temperatures in two shower rooms, with one room having water too cold and another too hot, exceeding safe limits. The Maintenance Supervisor, new to the role, confirmed the temperatures and acknowledged the absence of required water temperature logs. Despite no reported injuries, the facility did not adhere to its policies for regular temperature checks, compromising resident safety.
A resident with chronic conditions and paraplegia was found without access to a call light, which was on the floor under the bed. The resident's care plan did not address call light use, and staff were unaware of how it became inaccessible. The DON highlighted the importance of call light accessibility, which is monitored during morning rounds.
A resident with muscle wasting and feeding difficulties was not provided with a built-up spoon and straw during meal service, as required by her care plan. Instead, she received a regular fork, despite her request for a regular fork due to discomfort with the built-up spoon. The Dietary Manager acknowledged the oversight, which could impact the resident's ability to eat and drink.
A facility failed to ensure safe and sanitary storage of food items in a resident's personal refrigerator. Observations showed unlabeled and undated sliced summer sausage, confirmed by a CNA and the DON. The facility's policy requires perishable foods to be labeled and dated, but this was not monitored by the night shift nurses.
A facility failed to accurately document a resident's code status, with discrepancies between the admission record, consolidated orders, and care plan conference. The resident was documented as full code in some records but incorrectly as DNR in a care plan conference. The MDS coordinator acknowledged the error, noting that charge nurses rely on the code status book and orders for accurate information.
Failure to Protect a Resident From Ongoing Verbal and Emotional Abuse by an LVN
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and emotional abuse and intimidation by an LVN over an extended period. The resident was an older female with COPD, paraplegia, muscle weakness, major depressive disorder, nicotine dependence, insomnia, dementia without behavioral disturbance, psychotic/anxiety/mood disturbance, and wheelchair dependence. Her care plan reflected depression and impaired cognitive function due to dementia, and her most recent MDS showed a BIMS score of 14, indicating intact cognition. The care plan identified her as a smoker but did not include any documentation of abuse allegations. On one documented occasion, a progress note dated 11/10/2025 at 9:00 p.m. reflected that LVN B witnessed an argument in which LVN A told the resident, "You need to get off of my hall and go back down to your room right now," and, "I am not your nurse, and I want you off of my hall and don't comeback down here." The resident reported to LVN B that LVN A had "popped her in the mouth," and LVN B completed a head‑to‑toe assessment and notified the physician. The allegation was reported to the ADM/abuse coordinator and to the State Survey Agency, and the facility’s investigation and a prior state survey found the physical abuse allegation unsubstantiated; however, the verbal interaction and the resident’s report of being struck were documented. The interim DON later stated that this interaction was not considered sufficient evidence to substantiate abuse. Multiple interviews described a pattern of ongoing intimidating and exclusionary behavior by LVN A toward the resident from the time LVN A began working at the facility until her termination. The resident stated that when LVN A was on shift, she had to avoid the nurse’s station because LVN A would stop her, grab her electric wheelchair controller, and turn her around, and that LVN A refused to take her out for smoke breaks. The resident reported that her cigarettes were moved from the 300‑hall nurse’s station because LVN A did not want them there, and that she had to take a longer route to therapy to avoid passing the nurse’s station when LVN A was present. She described initially feeling bad and sad while watching LVN A and other residents smoke without her and said she adjusted by avoiding contact, communication, and proximity to LVN A. Staff interviews corroborated that LVN A spoke rudely to the resident, denied her smoke breaks, and restricted her from going near the nurse’s station when LVN A was on shift. The HS stated that LVN A intimidated the resident by making rude comments, telling her she was not allowed near the nurse’s station, and refusing to take her out to smoke, requiring other staff to come off the floor to do so. The HS also reported that the resident would travel the long way around the facility to avoid LVN A and that the resident’s cigarettes were moved from the nurse’s station to the memory care nurse’s station after LVN A objected to them being there. The DON acknowledged having to counsel LVN A about her attitude and unprofessional interactions and stated she had redirected LVN A after LVN A told the resident she could not drive her motor wheelchair around the nurse’s station because LVN A did not want the resident around her following the earlier abuse allegation. Despite these observations and reports, the facility did not update the resident’s care plan to reflect the abuse allegations or the ongoing intimidation and did not recognize or substantiate the pattern of verbal and emotional abuse and intimidation toward the resident.
Failure to Complete Timely and Accurate Transfer/Discharge Documentation for a Resident Sent to Hospital
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete, accurate, and timely transfer/discharge documentation for a cognitively impaired resident who was sent to the hospital for stroke-like symptoms. The resident was an elderly female with multiple diagnoses, including depressive episodes, GERD, anemia, insomnia, hyperkalemia, and diaphragmatic hernia, and had dementia with impaired cognition (BIMS score of 4), communication problems, unclear speech, ADL self-care deficits, and limited mobility. The resident’s face sheet showed no discharge date, and her care plan and MDS confirmed significant cognitive and functional impairments. According to family and staff interviews, an LVN observed stroke-like symptoms and ultimately called 911 to transfer the resident to the hospital, reporting that the resident had shown such symptoms for approximately 24 hours without the family being notified. Family reported they did not receive an official call from the facility about the change in condition or transfer, and no one from the facility contacted them to check on the resident’s status after the transfer. The attending physician later stated that she had been called by the LVN and had directed an immediate transfer to the hospital due to stroke-like symptoms. Multiple staff, including the HS, LVN C, the Med Aid, the interim DON, and the ADM, confirmed that the responsible nurse (LVN A) did not complete required documentation related to the resident’s change in condition and discharge. Specifically, there was no SBAR, no change-of-condition note, and no discharge summary completed at the time of transfer, and the resident’s clinical record contained no notes reflecting physician and family contacts, the reason for transfer, or how and when the resident left the facility. The interim DON and ADM stated that the missing SBAR prevented the discharge summary from being triggered and kept the discharge from appearing on the ADT report within 24 hours. The discharge summary was only completed later by the interim DON after surveyor intervention, confirming that the facility failed to ensure timely and accurate transfer/discharge documentation to support continuity of care.
Failure to Complete Psychosocial Assessment After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with professional standards of practice. The resident was an older female with paraplegia, COPD with acute exacerbation, major depressive disorder, dementia, psychotic/anxiety/mood disturbance, and nicotine dependence. Her care plan addressed impaired cognitive function related to dementia and the need for antidepressant medication for depression, but it did not include any focus or interventions related to an abuse allegation. A quarterly MDS showed a BIMS score of 14, indicating intact cognition. On one day in November, nursing notes documented multiple interactions between the resident and LVN A. In the morning, LVN A recorded that the resident became verbally abusive and used a racial slur toward her when upset about a delayed smoke break; LVN A then requested that LVN B take the resident out for smoke breaks. Later that evening, LVN B documented a cognition/behavior/agitation event in which LVN A yelled at the resident in the hallway, told her to get off the hall and return to her room, and stated she was not the resident’s nurse and did not want her on that hall. The note indicated that arguing occurred, but that the resident and LVN A went their separate ways with no injuries, pain, or signs of distress or discomfort observed at that time. Subsequently, a nursing note by the DON documented that, after this occurrence, the resident voiced that LVN A had “popped her in the mouth.” The DON performed a head-to-toe assessment and notified the resident’s responsible party and the physician. Additional documentation by LVN B indicated no adverse skin issues and described the resident as having patterned verbal behavior with no adverse mental, emotional, or physical effects. During interview, the interim DON stated that, despite the resident’s allegation of being struck, the facility did not complete a follow-up psychosocial assessment or any risk assessments to determine whether the resident had experienced psychological harm from the event. The administrator confirmed he was unaware that a psychosocial evaluation had not been completed following the abuse allegation and that the expectation had been for the social worker to initiate such an evaluation, which did not occur.
Failure to Document Resident Change in Condition and Emergency Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records and incident/change-of-condition documentation for a resident who experienced a significant change in condition and was transferred to the hospital. The resident was an elderly female with dementia, muscle wasting, gait abnormalities, and muscle weakness, who had an ADL self-care deficit and communication problems but was usually understood and usually understood others. Her Quarterly MDS showed a BIMS score of 4, indicating impaired cognition. The care plan identified limited physical mobility and use of antidepressant medication with risk for side effects. The resident’s face sheet showed she had been admitted to the facility with no discharge date recorded at the time of review. Family members and staff provided differing accounts of the events leading up to the resident’s transfer. One family member reported receiving a call from an LVN stating the resident had stroke-like symptoms and was sent to the ER, and later learned from the hospital that the resident had a stroke and was med-flighted to a higher level of care. This family member stated that the LVN told her the resident had shown stroke-like symptoms for about 24 hours without the family being notified, and that the LVN had instructed another nurse to monitor the resident for stroke-like symptoms before going off shift. The LVN reportedly told the family member she called 911 against facility protocol and was terminated for sending the resident to the ER without prior physician consent. The family member also stated that no one from the facility had officially notified her of the resident’s discharge with a change in condition or checked on the resident’s status. Multiple staff interviews showed that the resident’s change in condition and subsequent transfer were not properly documented in the clinical record. The HS reported being informed by the LVN that a med aide had observed the resident in and out of consciousness, but the HS questioned how the resident could have been unconscious for two shifts without any reports. LVN C stated that when a med aide relayed family concerns that the resident was not feeling well, she assessed the resident, found vital signs normal, and the resident stated she was fine; she then told the oncoming LVN to watch for changes. The med aide reported that during an evening medication pass, the resident was asleep, did not receive medications, and a family member expressed concern about the resident’s appearance; the med aide noted the resident appeared asleep with some whites of her eyes visible, asked a CNA about the resident’s status, and informed LVN C and then LVN D about the missed medications. The med aide stated there was a rumor that a family member spoke to LVN C about the resident’s condition and that no one checked on the resident for 12 hours, and that when LVN A came on shift, the resident’s blood pressure was 181/131, prompting the LVN to call 911. The interim DON stated that on the day of the change in condition, the resident required immediate transfer by ambulance to a higher level of care, and that as the resident’s nurse, LVN A should have completed an SBAR/change-of-condition report documenting the date, time, assessment findings, vital signs, medications, and notifications to the physician and family. The interim DON confirmed there was no SBAR, no discharge summary, and no nursing progress notes detailing or summarizing the resident’s need for hospital transfer or her condition at the time of transfer, and that the absence of the SBAR also affected the resident’s appearance on the ADT list and initiation of the discharge summary. The administrator reported that when a family member requested the resident’s clinical records, he could only provide the last hospital notes in the progress notes and that he did not have more detailed information because he had not obtained it from staff. He further stated that LVN A had not completed the required change-of-condition/SBAR documentation describing when, where, and why the resident was sent to the hospital. Physician documentation showed that a provider had assessed the resident the day before the event and noted no issues, and that later, the physician was informed by LVN A that the resident had elevated blood pressure and eyes rolling back, and directed the nurse to call 911 for immediate transfer due to stroke-like symptoms. The discharge summary for the resident was only completed and signed several days later, after surveyor intervention, confirming that the facility failed to contemporaneously document the resident’s change in condition and transfer in accordance with professional standards and regulatory requirements. The facility’s own admission, transfer, and discharge log reflected that the resident was discharged to an acute care hospital on the date of the change in condition, but the clinical record at that time lacked corresponding nursing notes, SBAR, or timely discharge summary documenting the resident’s status, assessments, and notifications. Staff interviews consistently indicated that LVN A, as the charge nurse, was responsible for completing the change-of-condition documentation and that this was not done. The interim DON acknowledged that it was the DON’s responsibility to ensure the charge nurse completed the SBAR and that the process “fell through” and the discharge was not reviewed. As a result, the resident’s clinical record did not contain complete and accurate information about the change in condition, the care provided, or the notifications made at the time of the emergency transfer, which the report states had the potential to affect all residents by compromising continuity of care, clinical decision-making, and resident safety.
Failure to Maintain Sanitary and Safe Environment Due to Mold Contamination
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by the presence of a black, moldlike substance on ceiling tiles throughout the building. Observations on multiple occasions revealed blackened ceiling tiles in several locations, including outside the Soiled Utility room, near resident rooms, across from the Therapy Gym, over a Nurse's Station, and in the Therapy Room. Interviews with staff indicated that the facility had been without a Maintenance Director for two weeks, and no one had performed necessary repairs or maintenance since the previous director's departure. The previous Maintenance Director had regularly cleaned and replaced affected tiles, but these tasks had not been continued. Additionally, the facility administrator questioned whether the substance was black mold and stated that repairs were being made as issues were identified, but acknowledged ongoing challenges due to the building's age. An anonymous interview revealed that staff were aware of extensive mold issues, particularly related to the air conditioning system, which had eroded drip pans and frequent leaks causing water damage to ceilings, walls, and light fixtures. The anonymous source also alleged that the administrator instructed the Maintenance Director to cover up mold odors with paint and to patch over visible mold rather than fully remediate it. The facility did not have a policy on Physical Environment available when requested, and a review of the Resident Rights policy indicated residents' rights to a dignified existence in an environment that promotes quality of life and protects their rights.
Resident Abuse Incident by Staff Member
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member. The incident involved a resident with severe cognitive impairment due to dementia, who was found on the floor by a medication aide (MA) and a certified nursing assistant (CNA). During the process of assisting the resident back to bed, the resident, who was agitated and confused, began swinging her arms and inadvertently hit the MA in the face. In response, the MA reacted by hitting the resident back in the face, which constitutes physical abuse. This incident was witnessed by a licensed vocational nurse (LVN) who was present during the event. The resident's care plan noted a history of trauma and advised staff to avoid touching the resident unless necessary for safety, indicating that the staff's actions were not in alignment with the care plan. The facility's failure to prevent this incident of abuse highlights a lapse in ensuring the safety and dignity of the resident. The staff involved had previously received training on abuse and neglect, as well as behavior management for residents, yet the incident still occurred, indicating a failure in applying this training effectively during the incident.
Deficiencies in Shower Room Cleanliness and Safety
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in two shower rooms, as observed during a survey. In the first shower room, there were issues such as soap scum and hard water stains on the tiles, a dirty shower mat with black stains, and a shower chair backrest with hard water stains. Additionally, a reddish substance was found under the shower chair. The Laundry/Housekeeper and Maintenance Supervisor confirmed these observations, noting that despite cleaning efforts, the stains remained. The water temperature in this shower room was recorded at 96.8 degrees Fahrenheit. In the second shower room, a tile was missing, and there was mildew buildup on the vent. The shower chair under the seat also had a reddish substance. The Maintenance Supervisor, who had started two weeks prior, noted that the water temperature in this room was 124.1 degrees Fahrenheit, which he acknowledged was too hot, preferring it to be no more than 110 degrees Fahrenheit. Interviews revealed that the housekeeper did not clean under the shower mat or the tiled walls and floors. The facility lacked water temperature logs, and the ADM/DON confirmed that no residents had suffered burns from the hot water. The facility's policy on resident rights emphasized the importance of a safe and clean environment.
Insufficient Weekend RN Staffing in Q2 2024
Penalty
Summary
The facility failed to maintain sufficient nursing staff to ensure resident safety and well-being during the second quarter of 2024. Specifically, the facility did not have registered nurse (RN) coverage on several weekends, including February 10, 11, 25, March 23, 24, 30, and 31. This lack of coverage was attributed to the facility's remote location, which made it difficult to attract and retain weekend RNs. The Director of Nursing acknowledged the shortage and noted that it could potentially lead to increased readmission rates. The facility's policy, revised in August 2006, requires an RN or LPN to be on duty 24 hours a day, seven days a week, which was not adhered to during the specified dates.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards in the storage, preparation, distribution, and serving of food, as observed in their only kitchen. During an inspection, it was noted that items in the walk-in refrigerator were not labeled with open or preparation dates. Specifically, three trays of unlabeled drinks, an opened milk jug, a small jar of jalapenos, a small jar of mayonnaise, and a small squeeze bottle of mayonnaise were found without labels indicating when they were opened. This lack of labeling could potentially lead to foodborne illnesses among residents who consume meals prepared in the kitchen. Additionally, a dented can of tomatoes was found in the dry storage area, mixed with other canned goods, despite the facility's policy that dented cans should be placed on a designated shelf for return to the vendor. The Dietary Manager acknowledged that all open foods in the refrigerator should be labeled with the date opened and that dented cans should be identified and separated upon delivery. The failure to label open items and the presence of a dented can in the storage area were identified as risks for foodborne illness.
Deficiency in Shower Room Water Temperature Management
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents in two shower rooms. In Shower Room 1, the water temperature was recorded at 96.8 degrees Fahrenheit, which is below the recommended range. In Shower Room 2, the water temperature was excessively high at 124.1 degrees Fahrenheit, exceeding the maximum safe limit of 110 degrees Fahrenheit. The Maintenance Supervisor, who had been in the position for only two weeks, confirmed these temperatures during observations and interviews. Additionally, it was revealed that the facility did not maintain water temperature logs, which are required to ensure consistent monitoring and safety. Interviews with the Administrator (ADM) and Director of Nursing (DON) indicated that no residents had reported injuries due to the water temperature issues, and there were no recorded grievances or concerns related to water temperature in the past six months. However, the facility's policies from 2003 and 2016 clearly outlined the need for regular temperature checks and logs to ensure a safe environment. The lack of adherence to these policies and the absence of water temperature logs contributed to the deficiency, potentially affecting the residents' comfort and safety.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents to maintain their independence and safety. The resident, a 64-year-old female with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and paraplegia, was found to have her call light on the floor under the bed. This situation was discovered during an observation and interview, where the resident expressed concern about not being able to call for help if needed. The resident's care plan did not address the use of the call light, which is a critical oversight given her condition and need for assistance. Interviews with the CNA and the DON revealed that the call light's inaccessibility was not noticed until the surveyor's observation. The CNA, who was responsible for the resident, was unaware of how the call light ended up on the floor but acknowledged the potential risk of falls if the resident attempted to get assistance without it. The DON emphasized the importance of ensuring call lights are accessible and mentioned that charge nurses monitor this during morning rounds. However, the facility's policy, which requires call lights to be within reach, was not adhered to in this instance.
Failure to Provide Special Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who required them during meal service. Specifically, the staff did not ensure that the resident, who was diagnosed with muscle wasting, atrophy, and feeding difficulties, received a built-up spoon and a straw as indicated in her care plan. During a dining observation, the resident was given a regular fork instead of the required built-up spoon and was not provided a straw, which was contrary to her care plan and meal ticket instructions. The resident expressed that she found the built-up spoon uncomfortable and had requested a regular fork, stating she no longer needed a straw. However, the Dietary Manager could not recall when this request was made and acknowledged that not providing the built-up spoon or straw could make eating and drinking difficult for the resident. The facility's policy on adaptive eating devices requires the dietary department to sanitize and place the necessary utensils on the resident's tray, which was not followed in this instance.
Failure to Ensure Safe Storage of Residents' Food Items
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of residents' food items in personal refrigerators, specifically in one resident's room. Observations revealed that the personal refrigerator contained sliced summer sausage in an unlabeled and undated zip-lock bag. This was confirmed during an interview with a CNA, who acknowledged the presence of the unlabeled and undated food item. The Director of Nursing confirmed that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent consumption of spoiled foods. However, it was noted that the night shift nurses, who were responsible for overseeing this task, were not currently monitoring it. The facility's policy, revised in October 2017, requires perishable foods to be stored in resealable containers with labels indicating the resident's name, the item, and the use-by date.
Inaccurate Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented in accordance with accepted professional standards and practices for one resident. Specifically, there was a discrepancy in the documentation of the resident's code status. The resident's admission record and consolidated orders indicated a full code status, while a care plan conference document incorrectly recorded the resident as having a DNR status. This inconsistency was identified during an interview with the facility's administrator and the MDS coordinator, who acknowledged the error in the care plan conference documentation. The MDS coordinator noted that charge nurses rely on the code status book and orders for accurate information, rather than care plan conferences.
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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 Weimar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Schulenburg Regency Nursing Center | 7.8 mi | ★★★★★ | 8 | 0 |
| Paradigm At The Oak | 8.5 mi | ★★★★★ | 30 | 3 |
| Trucare Living Centers-columbus | 12.8 mi | ★★★★★ | 1 | 0 |
| Columbus Oaks Healthcare Community | 14.1 mi | ★★★★★ | 3 | 0 |
| Monument Rehabilitation And Nursing Center | 14.1 mi | ★★★★★ | 8 | 0 |
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