Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parkway Hills Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident was admitted with surgically repaired ankle and foot fractures and documented surgical wounds with staples, but no physician orders for wound care were obtained or documented for most of the month following admission, and the TAR showed no wound treatments during that time. Later, a wound care physician was consulted, orders were written, and treatments were documented, with subsequent notes indicating staple removal and resolution of most wounds. The wound care nurse stated it was her responsibility to assess new wounds and contact the physician for orders, acknowledged she did not recall obtaining orders for this resident, and stated she should have done so. The DON confirmed the expectation that the wound care nurse obtain and document physician orders for wound monitoring and treatment, in line with the facility’s clinical protocol requiring documentation of current treatments.
A resident with paraplegia was transferred to a GACH and, shortly after admission, was documented as calm, cooperative, medically cleared to return, and expressing a desire to go back to the original SNF, where an active bed-hold was in place. Despite this, the facility declined to readmit the resident when the hospital attempted to discharge him back, and instead the resident was later discharged to another SNF. In interviews, the AD and Administrator confirmed the decision not to readmit, which conflicted with the facility’s bed-hold and return policy requiring residents seeking to return within the bed-hold period to be allowed back to their previous room and evaluated based on their current condition.
The facility failed to maintain a safe and homelike environment, with hallway floors taped and missing sections creating tripping hazards, and a wobbly handrail posing risks to residents and staff. Two residents, one using a cane and another with a history of falls, expressed concerns about these conditions. The maintenance director acknowledged the issues, which predated his employment, and admitted to lacking a routine schedule for checking handrails.
The facility failed to staff an RN for at least 8 hours a day for 18 days between January and March 2024. Despite having sufficient LNs and CNAs, the facility could not retain RN services and had no staffing waivers. The DON highlighted the importance of an RN for managing staff and resident care. The absence of an RN had the potential to compromise resident care quality.
A long-term care facility experienced a 50% medication error rate during a medication pass observation. Errors included a nurse failing to administer full doses to a resident via a G-tube, another nurse delaying a resident's morning medications by over three hours, and a third nurse unable to administer a diabetes medication due to unavailability. The errors involved medications critical for managing conditions like seizures, hypertension, and diabetes.
Three residents in a LTC facility experienced significant medication errors. A resident did not receive the full dosage of medications through a G-tube due to improper administration. Another resident's morning medications were administered over three hours late, including critical medications for diabetes and hypertension. A third resident did not receive a diabetes medication because it was unavailable in the medication cart. These errors highlight issues in medication administration and availability.
The facility failed to ensure kitchen staff were competent in operating and documenting the use of low-temperature dishwashers. Observations revealed dishwashers were unsure of proper procedures for taking temperature and chlorine samples, leading to inaccurate logs and potential risks of foodborne illness. The Dietary Manager acknowledged the need for accurate documentation to ensure proper machine functioning.
The facility failed to provide palatable and flavorful meals, potentially affecting residents' meal intake and health. Residents reported issues such as bland, cold, and repetitive food, with some dietary needs not being met. A test tray observation confirmed the lack of seasoning and unsatisfactory texture in meals, highlighting a deficiency in food quality.
The facility failed to store soy sauce and teriyaki glaze as per manufacturer's instructions, requiring refrigeration after opening. Additionally, the low-temperature dishwasher did not reach the necessary rinsing temperature for sanitization, with staff unsure of proper temperature recording procedures. These issues could increase the risk of foodborne illness.
A resident's MDS was inaccurately coded regarding their pneumococcal vaccination status, leading to incorrect data submission to the federal database. Despite consenting to vaccines, the resident did not receive an updated pneumonia vaccine, as confirmed by the IP nurse and the resident. The DON acknowledged the error, stating the MDS should reflect accurate assessment per the RAI manual.
A resident with obstructive sleep apnea had a care plan that was not updated to include specific details about their CPAP machine's settings and cleaning procedures. Observations showed the CPAP machine was present but not in use, and staff interviews confirmed the resident used the machine at night. The facility's policy required detailed care plans, but this was not reflected in the resident's documentation, leading to a deficiency.
Two residents in the facility did not receive necessary assistance with nail care, despite facility policies requiring weekly trimming during showers. One resident, with hemiplegia and hemiparesis, had long, untrimmed nails with debris, while another resident with dementia had long, jagged nails. Staff interviews revealed a lack of action due to uncertainty and fear of causing harm, leading to a deficiency in care.
A resident with obstructive sleep apnea used a CPAP machine without a documented physician's order for its settings, leading to potential inappropriate care. The resident brought her own CPAP machine, and staff were unaware of the preprogrammed settings. The facility's policy required documentation of CPAP settings but lacked guidance on obtaining a physician's order.
A resident with a history of epilepsy and moderate cognitive deficits had an unlabeled medication cup left unattended on their bedside table. A nurse admitted to leaving the medications, which included Clonazepam and Depakote, because the resident did not want to take them immediately. Facility staff acknowledged that medications should not be left unattended due to risks of divergence and choking hazards.
The facility failed to maintain infection control procedures for three residents, including not changing oxygen tubing weekly for two residents and improper storage of a CPAP mask for another. The respiratory therapist was on emergency leave, leading to lapses in changing and labeling oxygen tubing. Additionally, a CPAP mask was not stored in a plastic bag as required, and there was no documentation of its cleaning. These deficiencies increased the risk of infection transmission.
The facility failed to offer and administer updated pneumococcal vaccines to two residents, despite having consent forms and CDC recommendations. One resident, cognitively intact with a history of pneumonia, was not offered the vaccine, while another resident with a G-tube and high-risk status had an incomplete consent form. The DON acknowledged the importance of vaccine administration, but the facility did not follow its policy, leading to the deficiency.
The facility did not meet the minimum square footage requirements for resident rooms, with some rooms providing less than the required 80 square feet per resident. Despite this, there was no observed adverse effect on residents' health or quality of life, and a waiver for the room size variance was recommended.
A resident with functional quadriplegia lacked adequate visual privacy during personal care due to insufficient curtain placement, allowing a roommate to view her when accessing the shared bathroom. The Maintenance Director acknowledged the issue and noted that adding a curtain would be a simple fix.
Failure to Obtain and Document Physician Orders for Surgical Wound Care
Penalty
Summary
The facility failed to obtain and follow treatment orders for a resident’s surgical foot and ankle wounds. The resident was admitted with a lateral malleolus fracture that had been surgically repaired, and nursing documentation on the day after admission noted surgical wounds with staples on the right foot and ankle. The physician’s History and Physical confirmed admission following a fall and ankle fracture with surgical repair. However, review of the physician’s orders from admission through late in the month showed no treatment orders for the surgical wounds during that period, and the Treatment Administration Record (TAR) documented that no wound treatments were performed for the surgical sites during most of the month. A wound care physician was consulted by the primary care physician later in the month to evaluate and treat the surgical wounds, and wound care orders were then written and carried out as documented on the TAR for the remaining days of the month. A subsequent wound care physician note indicated that surgical staples had been removed and most of the wounds had resolved, with instructions to continue wound care. The wound care nurse reported that she had assessed the resident’s skin and wounds at admission and five days a week thereafter, acknowledged that it was her responsibility to contact the physician for treatment orders, and stated she did not remember calling for such orders. She further stated that she should have obtained treatment orders so nurses would know to monitor for signs of infection or other problems. The DON stated her expectation that the wound care nurse obtain physician orders to monitor and treat wounds and that written physician orders should have been present in the medical record as evidence that treatments were provided, consistent with the facility’s clinical protocol requiring documentation of current treatments.
Failure to Readmit Hospitalized Resident Despite Active Bed-Hold and Clearance
Penalty
Summary
The facility failed to permit a resident to return after hospitalization despite an active bed-hold and the resident’s expressed desire to return, resulting in a deficiency related to transfer/discharge practices. The resident, who had paraplegia and was originally admitted to the facility on an unspecified date, was transferred to a general acute care hospital (GACH) on 3/28/26. According to the GACH Case Manager Interdisciplinary Note dated 3/30/26, the resident was calm, cooperative, medically cleared for discharge back to the skilled nursing facility, and stated that he wanted to return there. The resident had an active bed-hold at the facility at that time. Despite this, the facility did not accept the resident back. The GACH Nursing Note dated 4/3/26 documented that the resident was instead discharged to a different skilled nursing facility four days after being initially cleared for discharge back to the original facility. In an interview on 4/9/26, the Admissions Director stated that the GACH attempted to send the resident back, but the facility decided not to readmit him. In a subsequent telephone interview on 4/14/26, the Administrator confirmed that the facility decided not to readmit the resident from the GACH. This decision was inconsistent with the facility’s “Bed-Holds and Returns” policy, revised October 2022, which states that residents with a bed-hold who seek to return within the bed-hold period are allowed to return to their previous room and that post-hospitalization return decisions for residents with clinical or behavioral concerns are to be based on their current condition at the time of transfer.
Unsafe and Unhomelike Environment Due to Poor Flooring and Handrail Conditions
Penalty
Summary
The facility failed to provide a safe and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. The hallway floors were found to be in poor condition, with gray duct tape used to secure the flooring and missing sections creating uneven surfaces. This was particularly concerning for residents with mobility issues, such as one resident who used a cane and expressed concern about the potential for injury due to the unstable flooring. Another resident, with a history of falling, also expressed fear about the missing flooring near their room. The maintenance director acknowledged the taped flooring and missing sections, noting that these issues predated his employment. Additionally, a handrail outside a resident's room was observed to be wobbly and secured with a loose screw, posing a risk to residents and staff. A CNA confirmed the handrail's instability and the danger posed by the uneven flooring. The maintenance director admitted to not having a routine schedule for checking handrails and was unaware of the issue until it was pointed out. The facility's policy on providing a safe and homelike environment was not adhered to, as evidenced by these observations.
Failure to Staff RN for Required Hours
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for at least 8 hours a day for 18 days between January 1, 2024, and March 31, 2024. This deficiency was identified through a review of the PBJ Staffing Data Report and CASPER Report 1705, which indicated that no RN hours were recorded for 19 days within the specified period. The Staffing Coordinator confirmed that on specific dates in January, February, and March, there was no RN scheduled for at least 8 hours. Despite having sufficient Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) on those days, the facility was unable to retain RN services and had no waivers for staffing. Attempts to use registry RNs were made, but the registry was found to be undependable. The Director of Nursing (DON) emphasized the necessity of having an RN on duty for at least 8 hours daily to manage staff, oversee resident care, and administer intravenous medications. The facility's policy on staffing mandates providing a sufficient number of skilled staff to meet resident care plans and facility assessments. The absence of an RN for the required hours had the potential to result in inadequate supervision and compromised quality of care for residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to prevent medication errors of less than 5% during a medication pass observation involving three licensed nurses and three residents. Licensed Nurse 1 (LN 1) administered medications to Resident 37 via a gastronomy tube but omitted one medication and failed to administer the full dose of several medications. The medications were not fully dissolved, leaving remnants in the medication cups, which resulted in Resident 37 not receiving the complete dosage necessary for managing health complications such as seizures, hypertension, and anxiety. Licensed Nurse 2 (LN 2) did not administer Resident 31's morning medications as scheduled, resulting in a delay of over three hours. This included medications for diabetes, high blood pressure, depression, and nutritional supplements. The delay was attributed to LN 2's incorrect assumption that Resident 31 was with the rehabilitation therapy team, which was not the case. The delay in medication administration was highlighted by the electronic medication administration record, which indicated the medications were late. Licensed Nurse 3 (LN 3) was unable to administer Resident 33's Januvia, a medication for diabetes management, because it was not available in the medication cart. LN 3 was unaware if the medication had been ordered and needed to notify the pharmacy for delivery. The Director of Nursing emphasized the importance of administering medications according to the facility's policy to prevent complications and ensure resident safety. The facility's medication error rate was calculated at 50%, significantly exceeding the acceptable threshold.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors. For Resident 37, a Licensed Nurse (LN) administered medications through a gastronomy tube but omitted one medication and did not ensure the full dose of medications was administered. The nurse was unsure of the medication being administered due to similar unlabeled medication cups and mixed all medications with the same syringe, leading to undissolved medication remnants. This resulted in Resident 37 not receiving the full dosage of medications necessary for managing epilepsy, hypertension, and mood stability. Resident 31 did not receive morning medications as scheduled because the nurse missed administering them, believing the resident was with the rehabilitation therapy team. The medications were administered more than three hours late, which included critical medications for diabetes, high blood pressure, and depression. The delay in administration was not acceptable, as it could lead to complications such as a hypertensive crisis or uncontrolled blood sugar levels. For Resident 33, the nurse was unable to administer Januvia, a medication for diabetes management, because it was not available in the medication cart. The nurse was unaware if the medication had been ordered and needed to notify the pharmacy for delivery. The absence of this medication could lead to hyperglycemia, highlighting the importance of ensuring medication availability and adherence to the facility's medication administration policy.
Incompetency in Dishwasher Operation and Documentation
Penalty
Summary
The facility failed to ensure that kitchen staff, specifically dishwashers, were competent in operating, documenting, and checking the water temperatures of two low-temperature dishwashers. This deficiency was identified through observations, interviews, and record reviews. During an observation, a dishwasher was seen taking a chlorine sample from the water exit site instead of directly from the dishes, and was unsure of where to take the temperature reading for the log. The temperature logged was 120 degrees Fahrenheit, but upon demonstration, the machine's thermometer showed 115 degrees Fahrenheit, and an independent reading showed 110 degrees Fahrenheit. The dishwasher was unaware of the appropriate temperature required. Further observations with the Dietary Manager revealed that the dishwashers were likely not taking accurate temperature readings, as the log showed consistent numbers despite different measurements. The Dietary Manager acknowledged that the machine was not reaching the appropriate temperature for rinsing and that manual washing would be necessary. Another dishwasher was also observed taking a chlorine sample incorrectly and was unaware of the proper procedure. The Dietary Manager admitted that the dishwashers should understand the importance of taking accurate temperatures and chlorine samples to ensure the machine's proper functioning and prevent foodborne illness.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and flavorful, which could potentially decrease meal intake and contribute to weight loss among residents. During a dining observation and interviews with residents, several concerns were raised about the quality of the food. Residents reported issues such as grilled cheese sandwiches not being cooked properly, dry macaroni and cheese, bland meat, cold food, and repetitive menu items like broccoli. Additionally, a vegetarian resident was served fish, and another resident on a renal diet received salty food. The facility's menu for the day included roast turkey with gravy and other items, but residents expressed dissatisfaction with the taste and temperature of the meals. A test tray observation conducted with the Dietary Manager (DM) and Registered Dietician (RD) revealed that the food served was bland and lacked seasoning. The temperatures of the dishes were taken, and while they were within safe ranges, the taste and texture were not satisfactory. The pureed diet meals had more seasoning compared to the regular diet meals. The DM acknowledged the importance of residents enjoying their meals to prevent weight loss and negative health impacts. The facility's policy on resident food preferences indicated that a variety of foods should be offered at each meal, but the observations and resident feedback suggested that this was not being effectively implemented.
Improper Food Storage and Dishwasher Temperature Issues
Penalty
Summary
The facility failed to store soy sauce and teriyaki glaze according to the manufacturer's recommendations, which required refrigeration after opening. During an observation and interview with the Dietary Manager (DM), it was found that opened containers of these sauces were stored in the dry storeroom, contrary to the instructions on the labels. The DM admitted to being unaware of the need for refrigeration for soy-based sauces and disposed of the sauces upon realizing the mistake. The facility's policy on food storage emphasized the importance of checking food labels to prevent serving spoiled or contaminated food, which could lead to foodborne illness. Additionally, the facility did not ensure that the low-temperature dishwasher reached the appropriate rinsing temperature for sanitization. An observation and interview with Dishwasher (DW) 11 revealed confusion about where to take temperature readings, with the DW incorrectly using a chlorine test strip for this purpose. The recorded temperature was below the required 120 degrees Fahrenheit, with independent measurements confirming this discrepancy. The DM acknowledged that the dishwashers might not have been taking accurate temperature readings and were likely recording incorrect data. The facility's policy required maintaining a temperature log to ensure the dishwashing machine operated within the manufacturer's guidelines to prevent the spread of foodborne illness through contaminated dishes.
Inaccurate MDS Coding for Resident's Vaccination Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident's vaccination status, leading to the submission of incorrect information to the federal database. Resident 31, who was readmitted to the facility with a history of congestive heart failure, was found to have an inaccurately coded MDS regarding their pneumococcal vaccination status. The resident's MDS indicated that their pneumococcal vaccination was up to date, despite the fact that an updated pneumonia vaccine had not been administered, as confirmed by the Infection Prevention (IP) nurse during a record review. Interviews and record reviews revealed that Resident 31 had consented to receive vaccines during the 2023-2024 vaccine season but was not offered or given an updated pneumonia vaccine. The resident confirmed receiving COVID-19 and flu vaccines but not the pneumonia vaccine. The Director of Nursing (DON) acknowledged the error, stating that the MDS should reflect an accurate assessment per the Resident Assessment Instrument (RAI) manual, which specifies coding the pneumococcal vaccination status as not up to date if the vaccine was not administered.
Failure to Update CPAP Care Plan for Resident with Sleep Apnea
Penalty
Summary
The facility failed to update a resident-centered care plan for a resident with obstructive sleep apnea who required the use of a CPAP machine. The resident was admitted with a diagnosis of obstructive sleep apnea, and during an observation, the CPAP machine was noted to be present but not in use, with the mask placed on the bed. Interviews with staff revealed that the resident applied the CPAP mask at night and removed it in the morning. A review of the care plan by the Minimum Data Set Nurse revealed that it lacked specific details regarding the CPAP machine's settings and the cleaning procedures for the tubing and mask. The facility's policy on comprehensive person-centered care plans emphasized the need for detailed interventions derived from thorough assessments, but this was not reflected in the resident's care plan. The absence of documentation for these critical aspects of care indicated that they were not being addressed, leading to a deficiency in providing appropriate care and treatment for the resident.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with nail care for two residents, Resident 43 and Resident 30, which was identified during a survey. Resident 43, who was admitted with hemiplegia and hemiparesis, had intact cognition but required substantial assistance with personal hygiene due to functional limitations in the upper extremity. Observations revealed that Resident 43 had long, untrimmed fingernails with debris underneath, and the resident reported that no one had cut his nails for a long time. Despite the facility's policy requiring weekly nail care, staff interviews indicated a lack of action due to uncertainty about the resident's health condition and fear of causing harm. Resident 30, diagnosed with dementia and muscle weakness, also had long and jagged fingernails. The resident expressed a desire for assistance with nail trimming, but observations over several days showed no change in the condition of the nails. Interviews with staff revealed that nail care was expected to be provided during shower days, but this was not done for Resident 30. The facility's policy allowed CNAs to trim fingernails unless the resident had diabetes, yet the necessary care was not provided. The facility's policy and procedure documents indicated that nail care should be performed weekly with showers and as needed. However, the failure to adhere to these guidelines resulted in the deficiency, as both residents did not receive the required assistance with nail care, potentially affecting their dignity and increasing the risk of infection and injury.
Lack of Physician's Order for CPAP Settings
Penalty
Summary
The facility failed to ensure a physician's order for the settings of a continuous positive airway pressure (CPAP) machine for a resident diagnosed with obstructive sleep apnea. The resident, who brought her own CPAP machine from home, did not have a documented physician's order specifying the CPAP settings. During an observation, the CPAP machine was seen on a plastic container beside the resident's bed, with the mask placed on the bed. Interviews with the licensed nurse and respiratory therapist revealed that the CPAP was used during sleep hours at preprogrammed settings, but there was no knowledge of what those settings were, nor was there an order to verify them. The resident expressed concern that staff might alter the CPAP settings, as they were not documented in the physician's order. The Director of Nurses confirmed that CPAP settings should be included in the physician's order to ensure staff are aware of the correct settings. A review of the facility's policy and procedure on CPAP/BIPAP support indicated the need to document mode and settings in the resident's medical record, but it did not provide guidance on obtaining a physician's order for the CPAP machine prior to its use.
Unsecured Medication at Resident's Bedside
Penalty
Summary
The facility failed to ensure that medications for a resident were secured and locked during a medication storage inspection. During an observation, a clear medication cup containing six medications was found unlabeled and unattended on the bedside table of a resident who had been readmitted to the facility with a history of epilepsy and moderate cognitive deficits. The resident stated that a licensed nurse had left the medication cup on the table for later consumption. A certified nursing assistant confirmed witnessing the medication cup on the table and noted that medications should not be left unattended for safety reasons. The licensed nurse admitted to leaving the medications at the resident's bedside because the resident did not want to take them at that time, and the nurse did not want to delay administering medications to other residents. The medications included Clonazepam, fenofibrate, fish oil, a multivitamin, vitamin D, and Depakote. Another licensed nurse and the Director of Nursing both stated that medications should not be left unattended due to the risk of medication divergence, potential medication errors, and the possibility of causing a choking hazard. The facility's policy on medication storage requires that all drugs and biologicals be stored in a safe, secure, and orderly manner.
Infection Control Deficiencies in Oxygen Tubing and CPAP Mask Management
Penalty
Summary
The facility failed to implement and maintain infection control procedures for three residents, leading to potential risks of infection. For Residents 27 and 34, the facility did not adhere to its policy of changing oxygen tubing weekly. Resident 27, who has chronic respiratory failure, COPD, and congestive heart failure, was observed with oxygen tubing labeled from two weeks prior, and there was no consistent labeling or changing of the tubing. Similarly, Resident 34, with diagnoses including congestive heart failure and chronic respiratory failure, had oxygen tubing that was not changed weekly as required. The respiratory therapist, who was responsible for changing the tubing, was on emergency leave, and the task was not adequately covered by other staff, leading to lapses in the procedure. Resident 6, diagnosed with obstructive sleep apnea, had issues with the storage and maintenance of their CPAP mask. The mask was observed on the floor and not stored in a plastic bag as per infection control guidelines. The licensed nurse stated that the mask should be stored in a plastic bag when not in use, but the resident reportedly refused this practice, although the resident later denied such a refusal. The respiratory therapist did not document the cleaning of the CPAP mask and tubing, which was supposed to occur weekly, further contributing to the deficiency. The facility's policies and procedures, including those for infection control and CPAP/BIPAP support, were not adequately followed, leading to these deficiencies. The lack of proper labeling, changing, and storage of medical equipment increased the risk of infection transmission among residents and staff. Interviews with staff, including the respiratory therapist, licensed nurse, and director of nursing, confirmed the expectations and importance of these procedures, highlighting the lapses in adherence to the facility's infection control policies.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer and administer an updated pneumococcal vaccine to two residents, Resident 31 and Resident 37, as per the Centers for Disease Control (CDC) recommendations. Resident 31, who was cognitively intact and had a history of congestive heart failure and pneumonia, was readmitted to the facility and had a consent form dated for the vaccine season. However, the vaccine was not administered, and the resident confirmed that he was not offered the updated pneumonia vaccine, although he would have consented if it had been offered. Resident 37, who had a history of epilepsy and required nutritional and medication administration through a G-tube, was also not offered the updated pneumonia vaccine. The consent form for Resident 37 was incomplete, with no indication of consent or refusal for the pneumonia vaccine. The Infection Prevention (IP) nurse acknowledged that the vaccine was not offered due to the incomplete consent form, despite the resident's high-risk status for pneumonia infections due to his health condition. The Director of Nursing (DON) confirmed the importance of offering and administering vaccines to all residents if consented. The facility's policy, revised in October 2023, stated that pneumococcal vaccines should be administered unless medically contraindicated, already given, or refused, in accordance with CDC recommendations. However, the failure to adhere to this policy resulted in the deficiency noted in the report.
Room Size Deficiency in Resident Accommodations
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in four of its 28 resident rooms. Specifically, rooms designated for two residents only provided 71.5 square feet per resident, falling short of the 80 square feet requirement. Additionally, a room accommodating three residents offered only 73.66 square feet per resident, and a room with four residents provided 76 square feet per resident. Despite these deficiencies, the variations in room size were not observed to adversely affect the residents' health, safety, quality of care, or quality of life during the survey. The Department recommended the continuance of the room size variance/waiver for the affected rooms.
Inadequate Privacy Curtains Compromise Resident Privacy
Penalty
Summary
The facility failed to provide adequate visual privacy for a resident, identified as Resident 1, who was admitted with conditions including heart failure and functional quadriplegia, necessitating assistance with personal care. During an observation and interview, it was noted that the privacy curtain for Resident 1's bed did not extend to separate the walkway to the shared bathroom, allowing other residents to potentially view Resident 1 during personal care activities. Resident 1 expressed concerns about the lack of privacy, stating that if her roommate needed to use the bathroom while she was receiving care, the roommate would have a full view of her body due to the inadequate curtain placement. The roommate, identified as Resident 2, confirmed that accessing the bathroom required entering Resident 1's privacy curtain area, which would result in a clear view of Resident 1 during personal care. The Maintenance Director acknowledged the issue, stating that the current curtain setup did not prevent other residents from accessing the shared bathroom without breaching Resident 1's privacy. The director also mentioned that adding a curtain between Resident 1's bed and the walkway to the bathroom would be a simple solution. The facility's policy on confidentiality and personal privacy, revised in October 2017, emphasizes the importance of protecting residents' privacy during personal care, which was not upheld in this instance.
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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 La Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor Hills Nursing Center | 0 mi | — | 8 | 0 |
| Country Manor La Mesa Healthcare Center | 0.6 mi | — | 0 | 0 |
| Community Care Center | 1.2 mi | — | 0 | 0 |
| Grossmont Hospital D/p Snf | 1.2 mi | — | 0 | 0 |
| Grossmont Post Acute Care | 1.3 mi | — | 2 | 0 |
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