Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 Parker Post Acute during CMS and state inspections, most recent first.
Failure to Reassess Pain During Repositioning: A resident with sepsis, CHF, pneumonia, and a pressure injury reported severe pain during repositioning and incontinent care, but CNA and RN staff continued the care after he cried out and asked them to stop. The resident was known to have pain with movement, had scheduled oxycodone and PRN acetaminophen orders, and the care plan lacked documented pain interventions and monitoring details. Staff later acknowledged they should have stopped care and reassessed pain when the resident began moaning and reporting pain.
Staff failed to follow infection control practices during resident care, including not wearing required gowns and other PPE for residents on EBP and contact precautions, and not performing hand hygiene during wound care after glove contamination. An LPN contaminated gloves while dressing a wound, multiple staff entered a room for a resident with shingles without the required PPE, laundry was sorted without proper protective equipment, and a contaminated nasal cannula that had been on the floor was placed back on a resident.
Failure to honor resident choice and keep call light within reach: A cognitively intact resident requested to resume use of her electric wheelchair for greater mobility and independence, but the facility did not complete a safety reassessment after the request. Another resident with dementia, hearing loss, and mobility needs was repeatedly observed in bed with her call light on the floor and out of reach, and staff did not consistently ensure it was accessible.
Failure to report and investigate potential sexual abuse between two residents: staff found a resident with dementia naked in another resident’s room, but the incident was not reported to the State Agency and no formal investigation was documented. The residents were known to have a romantic relationship, yet the facility had no written evaluation of consent for either resident, and the DON, NHA, and SSD confirmed the lack of required documentation and reporting.
Failure to maintain a resident’s hearing device. A resident with significant hearing loss and impaired communication relied on a pocket talker after her hearing aid stopped working, but staff did not keep the device charged and it was often unavailable for use. Observations found the device and hearing aid stored in a bedside drawer while the resident could not hear staff unless they spoke very close to her. Interviews confirmed the pocket talker was her most effective communication method, that it only held a short charge, and that the issue was not documented in the EMR.
A resident with a hx of falls, gait/mobility impairment, and severe cognitive impairment had a care plan calling for the bed to remain in the lowest position, but staff repeatedly observed the bed left in the highest position. The resident had previously fallen during a shower when a hospice CNA could not catch the fall and the resident hit the back of his head. RN and ADON interviews confirmed the fall interventions were not being followed as written.
A resident with COPD, asthma, chronic respiratory failure with hypoxia, and OSA was found receiving oxygen above the physician-ordered 1 LPM. Staff observed the resident on 2.5 to 4 LPM via portable tank and concentrator, and a CNA changed the flow rate without verifying the order with the nurse. RN staff also failed to confirm the correct setting, and the resident stated 4 LPM seemed too much for her condition.
A resident with dementia and severe cognitive impairment was involved in a romantic relationship with another resident, but the EMR did not show that the facility assessed whether she could consent to a sexual relationship. Staff gave mixed opinions about her decision-making ability, with some saying she could consent and the DON stating she could not due to her cognitive status. The resident was found naked in the other resident’s bedroom, and the care plan documented the relationship, but there was no written consent evaluation for either resident.
A resident with multiple complex medical conditions was discharged without a documented assessment or arrangement for home oxygen therapy and timely home health services for intravenous antibiotics. The care plans and discharge summary indicated ongoing needs, but the facility did not confirm or document referrals for necessary equipment or services, resulting in a delay of home health care and missed medication doses.
Two residents in a LTC facility experienced multiple falls due to inadequate supervision and ineffective fall interventions. Despite being identified as high fall risks, the facility failed to consistently update care plans with new interventions or identify the root causes of the falls. This resulted in repeated falls and injuries, with one resident requiring hospital treatment twice.
A resident with severe cognitive impairments and multiple diagnoses, including low back pain and dementia, experienced excruciating pain that was not addressed by the facility for three and a half hours. The facility's pain management policy required the use of the PAINAD scale for non-verbal residents, but a numerical pain scale was used instead. Staff interviews revealed a lack of timely response and monitoring, leading to a failure in effective pain management.
The facility failed to implement baseline care plans within 48 hours of admission for two residents, omitting critical information such as dialysis schedules and wound care needs. The DON noted that admitting nurses were responsible for initiating care plans, but staff relied on admitting orders instead.
A resident with malignant bladder cancer missed several oncology and chemotherapy appointments due to the facility's failure to arrange transportation. Despite the facility's policy to assist with transportation, the resident's appointments were not documented in the electronic medical record, and staff were unaware of the missed appointments. A change in scheduling staff and lack of communication contributed to the oversight.
Failure to Reassess Pain During Repositioning
Penalty
Summary
The facility failed to provide effective pain management for a resident who reported significant pain during repositioning and incontinent care. Resident #64 was admitted with sepsis, acute respiratory failure, CHF, pneumonia, and a pressure-induced deep tissue injury of the left ankle. The resident was cognitively intact, required substantial assistance with care, and told staff that he had pain when moved or repositioned, rating it as 8 out of 10 when care was provided. During observation, CNA #5 and RN #5 repositioned and provided incontinent care while the resident repeatedly cried out that it hurt and asked the staff to stop. The resident moaned loudly and stated, “You don't know how bad it hurts,” but the staff continued the care instead of stopping to reassess his pain. RN #5 told the resident she would check for pain medication after care was finished, and then administered Tylenol 650 mg after the care was completed. The staff did not assess the resident’s pain level or location during the episode of acute pain. Record review showed the resident had orders for scheduled oxycodone 5 mg four times daily for pain and acetaminophen as needed, but the care plan did not include documented pain interventions, non-pharmacological measures, monitoring for medication effectiveness, or monitoring for opioid side effects. Interviews confirmed that RN #5 and CNA #5 routinely completed care first and reported pain afterward, and RN #5 stated she should have stopped care when the resident began moaning and saying he was in pain. The DON stated staff were expected to assess pain using verbal and nonverbal indicators, and the NHA stated that a complaint of pain should be treated as a new symptom every time.
Infection Control Failures With PPE, Hand Hygiene, Laundry, and Oxygen Tubing
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program during multiple resident care activities on all three floors. Staff did not consistently use the required PPE for residents on enhanced barrier precautions (EBP) or contact precautions, did not perform hand hygiene at key points during wound care, did not handle contaminated laundry in the manner described by facility policy, and did not manage oxygen tubing in a sanitary way. The report identifies these failures through direct observations and staff interviews involving residents with wounds, indwelling devices, and shingles. During EBP-related observations, an RN administered IV medication to a resident with a chest port without wearing a gown even though the door sign indicated gloves and a gown were required for resident care activities. Two CNAs assisted a resident with a mechanical lift transfer while wearing gloves but no gown. Another RN and CNA repositioned a resident with a left ankle wound while the resident was on EBP, and the CNA later stated she did not know the difference between contact precautions and EBP and had not been told the resident was on EBP. The DON stated that residents with wounds or indwelling devices were required to be on EBP and that gown and gloves were expected for high-contact direct care activities. Hand hygiene and contamination control also failed during wound care for a resident with a left heel wound. An LPN removed the old dressing, changed gloves without performing hand hygiene, touched a clipboard outside the room, returned to the room, and then reached into her scrub pocket for an ink pen before applying the new dressing. The LPN stated she did not realize her gloves had been contaminated and acknowledged the need for hand hygiene and glove changes between possible contamination points. The report also describes contact precaution failures for a resident with shingles: staff entered the room without PPE, including a scheduler, a CNA, a speech therapist, and another CNA who entered with a breakfast tray while wearing gloves but no gown or mask. Staff interviews showed differing understanding of the precautions, while RN and ADON interviews confirmed the resident remained on contact precautions. Additional infection control failures were observed in the laundry room and with respiratory equipment. Laundry staff sorted soiled laundry without wearing PPE except when handling sugar bags or biohazard bags, despite policy requiring gloves and other protective equipment when handling soiled laundry. The laundry worker described sorting items that sometimes contained fecal matter or urine and said she was caught off guard when contaminated laundry came down without PPE. Finally, an activities assistant untangled a resident’s nasal cannula after it had been on the floor several times and placed it back on the resident, then sought help from a CNA. The CNA later quickly reapplied the cannula, and both the CNA and DON/IP stated that a contaminated cannula should be replaced.
Failure to Honor Resident Choice and Keep Call Light Within Reach
Penalty
Summary
The facility failed to honor resident choice for a cognitively intact resident who requested to resume use of her electric wheelchair. The resident, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction, muscle weakness, depression, chronic pain syndrome, and muscle contracture, had been using a manual wheelchair after a prior incident in which she ran into a wall with her power wheelchair and fractured her foot. During a care conference, she again expressed interest in using her electric wheelchair for improved mobility and independence, but the record did not show that the facility reassessed whether it was safe for her to use it after the request was made. Documentation showed the resident’s request was discussed in care conference summaries and a psychiatric evaluation note, which stated the request was relayed to social services. The director of rehabilitation acknowledged being present when the resident expressed her desire to use the electric wheelchair, but said the facility was waiting for the resident’s sister to purchase a smaller electric wheelchair. The director of rehabilitation also stated that no safety assessment was completed when the resident requested to use her power wheelchair again. The facility also failed to keep another resident’s call light within reach. That resident had diagnoses including chronic kidney disease, dementia, right shoulder pain, muscle weakness, overactive bladder, and unspecified hearing loss, and required partial/moderate assistance with toileting, showers, and transfers. On multiple observations over several days, the resident was lying in bed with the call light on the floor under the bed and out of reach, and staff entered the room without ensuring it was accessible. The resident stated she usually yelled out for help because she did not know where her call light was and preferred not to yell when she needed assistance.
Failure to Report and Investigate Potential Sexual Abuse Between Two Residents
Penalty
Summary
The facility failed to investigate and report an alleged violation of potential abuse to the State Survey and Certification Agency for two residents. The report states that the facility did not timely report an incident involving possible sexual abuse between a resident with dementia and another resident, and it also did not document a formal investigation into what occurred. Facility policy required alleged violations involving abuse to be reported immediately, but not later than two hours after the allegation if abuse was involved, and to the state survey agency and adult protective services. Resident #56 had diagnoses including dementia with behavioral disturbance and cognitive communication deficit, and a prior MDS documented severe cognitive impairment with a BIMS score of 6. Resident #102 had Parkinson's disease with dyskinesia, auditory hallucinations, visual hallucinations, and moderate cognitive impairment with a BIMS score of 10. The record documented that Resident #56 was found naked in Resident #102's bedroom after dinner, and staff intervened by speaking to her, helping her get dressed, and moving her to the living room. The DON was aware of the incident. Interviews showed staff knew the residents had a romantic relationship, but the facility had no documentation of an investigation, no written evaluation of consent for either resident, and no documentation that the incident was reported to the State Agency. The DON stated the facility did not have documentation of an investigation or consent evaluation and did not think Resident #56 could consent due to her cognitive status. The NHA confirmed the incident was not reported to the State Agency and that the facility did not conduct a formal investigation. The SSD said she spoke with the residents and the representative, but this was not documented, and the resident's representative said he had not been informed of the incident.
Failure to Maintain Charged Hearing Device
Penalty
Summary
The facility failed to ensure proper treatment and assistive devices were available to maintain hearing abilities for one resident with documented hearing impairment. The resident, who had diagnoses including COPD with exacerbation, type 1 diabetes mellitus, bipolar disorder, a history of TIA/CVA without residual deficit, and cognitive communication deficit, had a BIMS score of 14 out of 15 and required assistance with some ADLs. Her care plan identified impaired communication due to hearing loss and documented that she was hard of hearing, declined hearing aids, and used a pocket talker for most communication. Observations showed the resident seated in her wheelchair without her hearing aid or pocket audio device and not responding to greetings until staff moved directly in front of her. During the observation, the pocket audio device and hearing aid were found in her bedside drawer. The resident stated her hearing aid had stopped working months earlier and that the pocket audio device often was not charged, only held a charge for about one hour, and was frequently forgotten by staff. She also said she felt helpless without hearing and was cut off from the world, and that she stopped using the device because it was usually not charged. Record review showed the resident’s ancillary services note documented bilateral hearing loss ranging from moderately-severe to profound and recommended rechargeable devices to reduce frequent battery changes. The EMR did not contain documentation about her hearing impairment issues, broken hearing aids, or charging problems with the pocket talker. Staff interviews confirmed the device was the resident’s most effective communication method, that she could not hear without it, and that the device did not hold a charge. The social services director stated she was unaware of the charging problems and that the resident had not been seen by audiology in 2025.
Failure to Follow Fall Interventions for a Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for Resident #46 by not implementing fall interventions as written in the care plan. Resident #46, who was over age 65, had diagnoses including history of falling, unspecified abnormalities of gait and mobility, and palliative care. The 3/2/26 MDS showed severe cognitive impairment with a BIMS score of 3 out of 15 and that the resident required substantial to maximal assistance with functional abilities. The care plan, initiated 5/27/25, identified the resident as at risk for falls due to deconditioning and included interventions such as keeping the call light within reach, keeping the bed in the lowest position, and keeping needed items within reach. Record review showed the resident had a fall on 6/3/25 while a hospice CNA was assisting with a shower; the CNA was unable to catch the fall and the resident hit the back of his head in the shower. During multiple observations on 3/9/26, 3/10/26, 3/11/26, and 3/12/26, the resident was seen resting in bed with the bed approximately three feet in the air. RN #6 observed the bed in the highest position and lowered it, stating the CNA did not leave the bed in the lowest position as the care plan required. The ADON stated the resident had specific fall interventions in the care plan and was not aware the bed had been left in the highest position.
Failure to Follow Ordered Oxygen Flow Rate
Penalty
Summary
The facility failed to provide respiratory care consistent with the resident’s physician’s order for continuous oxygen therapy. Resident #21 had diagnoses including COPD, moderate persistent asthma, chronic respiratory failure with hypoxia, major depressive disorder, and obstructive sleep apnea. The resident’s care plan identified altered respiratory status related to COPD, chronic respiratory failure, and asthma, and the March 2026 physician’s order directed continuous 1 LPM oxygen via nasal cannula to maintain oxygen saturation at or above 90%. During observations, Resident #21 was found receiving oxygen at settings above the ordered amount. On 3/10/26, CNA #3 transferred the resident’s nasal cannula from the room concentrator to a portable tank and set it at 4 LPM after the resident asked to reduce it to 2 LPM; the CNA complied without verifying the order with a nurse. On 3/11/26, the resident was observed with the portable oxygen tank set at 2.5 LPM. On 3/12/26, the resident was observed in bed with the concentrator set at 4 LPM, and RN #4 and CNA #4 confirmed the setting. The resident stated she used oxygen continuously and believed 4 LPM was probably too much for her condition. Record review showed the resident had been consistently receiving 2 LPM of oxygen in the electronic medical record, but the physician’s order remained 1 LPM. Staff interviews confirmed CNA #4 did not know the ordered liter flow and did not report the incorrect setting, and RN #4 stated she did not verify the concentrator setting at the start of her shift. The DON stated oxygen was a form of medication and that staff were required to follow oxygen orders.
Failure to Assess Consent for Romantic Relationship
Penalty
Summary
The facility failed to ensure that Resident #56, a resident with dementia and cognitive communication deficit, received appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Resident #56’s records showed severe cognitive impairment on the most recent MDS, with a BIMS score of 6 out of 15, and she required one-person assistance as needed for transfers, bathing, and toileting. Her care plans addressed dementia-related cognitive impairment and behavioral concerns, including interventions for routine, communication, and behavior management. The record also showed that Resident #56 and Resident #102 were involved in a romantic relationship. A nursing progress note documented that Resident #56 was found naked in Resident #102’s bedroom after dinner, after which staff assisted her to dress and she spent the rest of the evening in the living room. The comprehensive care plan reflected the relationship between the two residents, but the electronic medical record did not contain documentation that the facility assessed Resident #56 to determine whether she could consent to a sexual relationship. Staff interviews showed differing opinions about Resident #56’s ability to consent. A CNA and an LPN stated they believed she could make her own decisions and consent to a relationship, although the LPN also stated the resident was sometimes confused and had recently been unable to follow instructions. The DON stated she did not think Resident #56 could consent because of her cognitive status, while the SSD said there was no written documentation that consent had been evaluated for either resident. The facility also had an incident involving the residents that was referenced in a related deficiency for failure to timely report a potential sexual abuse incident to the State Agency.
Failure to Assess and Arrange Discharge Services for Oxygen and Home Health
Penalty
Summary
The facility failed to properly assess, arrange, and document discharge services for a resident who required ongoing oxygen therapy and intravenous antibiotics after discharge. The resident, who had a history of endocarditis, enterocolitis, sepsis, emphysema, COPD, heart failure, and pulmonary hypertension, was admitted with no oxygen therapy but began using supplemental oxygen during the stay. The care plans for pneumonia and respiratory issues included oxygen therapy, but there was no documented plan of care or discharge needs assessment for home oxygen services. Upon discharge, the resident's summary indicated a continued need for 2 LPM of oxygen via nasal cannula and ongoing intravenous antibiotics. However, the electronic medical record did not contain any physician's orders or referrals for home oxygen equipment or confirmation of home health services to provide antibiotic therapy after discharge. The home health provider did not begin services until four days after the resident left the facility, resulting in missed doses of antibiotics and a lack of oxygen therapy at home during that period. Interviews with facility staff revealed that the social services assistant sent a referral for home health services to the resident's insurance provider but did not confirm receipt or authorization. The DON was unable to locate a discharge needs assessment for oxygen or documentation of a referral for home oxygen. The NHA acknowledged that the resident was discharged before confirmation that a home health provider had accepted the referral, and the physician was not notified that services were not arranged prior to discharge. The facility's discharge planning policy required identification and documentation of discharge needs, involvement of the interdisciplinary team, and confirmation of post-discharge services, all of which were not met in this case.
Inadequate Fall Prevention and Supervision in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and effective fall interventions for two residents, leading to multiple falls and injuries. Resident #7, diagnosed with unspecified dementia, a history of falling, and muscle wasting, experienced 17 falls between June 2024 and March 2025. Despite the implementation of some interventions, such as fall mats and keeping the bed in a low position, the facility did not consistently update the care plan with new interventions after each fall. The facility also failed to identify the root cause of the falls, resulting in two incidents that required hospital transportation for treatment of injuries. Resident #4, with diagnoses including left-sided hemiplegia, muscle weakness, and a history of falling, experienced 12 falls between November 2024 and February 2025. The facility's interventions, such as ensuring the call light was within reach and frequent room checks, were insufficient to prevent further falls. The resident reported that she often had to wait too long for staff assistance, leading her to attempt transfers on her own, which contributed to her falls. The facility's policy required the interdisciplinary team to assess and evaluate fall risks and implement a plan of care for high-risk residents. However, the facility did not effectively implement or update fall interventions following each incident, nor did it adequately identify the root causes of the falls. This lack of effective intervention and supervision resulted in repeated falls and injuries for both residents.
Failure in Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide effective pain management for a resident with severe cognitive impairments and multiple diagnoses, including low back pain and dementia. The resident was on a scheduled pain regimen that included Tylenol and Aspercreme, but on a specific date, the resident began complaining of excruciating pain in multiple areas of her body. Despite the resident's severe pain, the facility did not address her complaints for three and a half hours, during which time the resident was administered Valium for hallucinations and anxiety. The facility's pain management policy required an interdisciplinary team to assess and manage resident pain, using tools like the PAINAD for residents unable to communicate verbally. However, the care plan for the resident did not specify pain goals or acceptable levels of pain, and the facility used a numerical pain scale instead of the PAINAD, which was more appropriate given the resident's cognitive impairments. The facility's records showed inconsistencies in the administration of pain medications and a lack of timely response to the resident's pain complaints. Interviews with staff revealed that the resident was typically quiet and did not usually complain of pain, which may have contributed to the delay in addressing her pain. The DON acknowledged that follow-up after administering pain medication should occur within one to two hours, or every 30 minutes for residents in excruciating pain. However, the facility's electronic medical record did not show regular monitoring of the resident's pain after her initial complaint, indicating a failure to adhere to the facility's pain management policy.
Failure to Implement Baseline Care Plans for New Residents
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, which is a requirement according to their policy. Resident #6, who was admitted with end-stage renal disease, a stage 3 pressure ulcer, and required maximum assistance for transfers, did not have pertinent medical information included in their baseline care plan. The care plan omitted details about the resident's dialysis schedule, wound care needs, and assistance required for activities of daily living, such as toileting and meal setup. Similarly, Resident #2, who had cognitive communication deficits, type 2 diabetes, and chronic kidney disease, also had an incomplete baseline care plan. Although the resident's chronic kidney disease and insulin use were documented, the care plan failed to include information related to the resident's dialysis care. The Director of Nursing indicated that the admitting nurse was responsible for initiating the baseline care plan, which was then audited for accuracy. However, the staff did not utilize the baseline care plan for new resident information, relying instead on admitting orders.
Failure to Arrange Transportation for Cancer Care Appointments
Penalty
Summary
The facility failed to ensure that a resident received necessary transportation services, resulting in missed medical appointments. The resident, who was over 65 years old and diagnosed with malignant bladder cancer, required regular oncology and chemotherapy infusion appointments. Despite the facility's policy to assist with transportation arrangements, the resident missed several critical appointments due to the facility's failure to arrange transportation. Interviews and record reviews revealed that the facility's scheduling process was flawed. The resident's care manager reported that transportation was confirmed for appointments, but the resident still missed them. There was no documentation in the resident's electronic medical record to indicate that the appointments were attended, and no progress notes were made regarding the missed appointments. Additionally, the facility staff, including registered nurses and schedulers, were unaware of the missed appointments, indicating a lack of communication and documentation. The facility experienced a change in scheduling staff during the period when the appointments were missed, which may have contributed to the oversight. The interim scheduler claimed to have arranged transportation but could not provide evidence of scheduling or billing for the missed appointments. The nursing home administrator was unaware of the missed appointments until informed during the investigation, highlighting a breakdown in the facility's internal communication and processes.
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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 Parker
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Stonegate | 1.6 mi | — | 0 | 0 |
| Center At Lincoln, Llc, The | 5.3 mi | — | 1 | 0 |
| Beth Israel At Shalom Park | 6.1 mi | — | 10 | 0 |
| Brookdale Greenwood Village | 7.3 mi | — | 5 | 0 |
| Hampden Hills Post Acute | 7.9 mi | — | 0 | 0 |
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