Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Parsons Presbyterian Manor during CMS and state inspections, most recent first.
A significant medication error occurred when a fatigued CMA administered another resident's medications to a cognitively impaired resident, leading to life-threatening hypotension. The resident, who had a history of hypertension, experienced a rapid drop in blood pressure and required emergency transport to the ED. The error was realized after administration, and the CMA continued to pass medications despite her fatigue.
The facility failed to properly maintain and dispose of garbage, leading to unsanitary conditions with open dumpster compartments and surrounding discarded building supplies. Staff confirmed the need to keep dumpster lids closed to prevent pest attraction, but the facility lacked a policy for proper garbage disposal.
The facility failed to submit accurate staffing data to CMS, missing 24-hour LN coverage on multiple dates across two fiscal quarters. Despite believing submissions were correct, discrepancies were found in the PBJ Staffing Data Report, revealing gaps in LN coverage.
A resident with multiple health conditions was verbally abused by a CNA, who called the resident 'lazy' in front of others. The incident was witnessed by two staff members but was not reported to management until nine days later, violating the facility's policy on prompt reporting of abuse.
A resident with severe cognitive impairment experienced a skin tear on his hand, but the facility failed to investigate the cause or implement immediate interventions to prevent further injury. Despite the resident's known risk for skin tears and need for assistance, the facility lacked a policy for root cause analysis, and staff did not document preventive measures after the incident.
A resident with a stage two sacral pressure ulcer was found to be using a malfunctioning pressure-relieving cushion in their recliner. Despite having a care plan that included a low air loss mattress and specific wound care instructions, the cushion was deflated and not reported by staff, leading to inadequate pressure reduction. The facility failed to monitor the cushion's status, as required by their policy on therapeutic support surfaces.
A resident with severe cognitive impairment and fall risk was transferred using a sit to stand lift with a broken safety belt, which had been in disrepair for over a week. Staff failed to report the issue, violating facility policy on equipment maintenance and resident safety.
Significant Medication Error Due to Fatigue
Penalty
Summary
The facility failed to prevent a significant medication error involving a cognitively impaired resident, R1, when Certified Medication Aide (CMA) R administered another resident's medications to R1. On the evening of 09/12/24, CMA R, who was reportedly fatigued, mistakenly gave R2's medications, Crestor 20 mg and Coreg 25 mg, to R1, along with R1's scheduled mirtazapine 15 mg. This error occurred during the supper meal when R1 and R2 were seated together at the dining table. CMA R realized the mistake after administering the medications and immediately checked R1's vital signs, which were stable at that time. R1, who had a history of hypertension and severely impaired cognition, experienced a significant drop in blood pressure following the medication error. Initially, R1's blood pressure was recorded at 158/74 mmHg, but it decreased to 82/45 mmHg and then to 75/37 mmHg within a short period. The resident exhibited symptoms of life-threatening hypotension, including tremors and unresponsiveness, prompting the nursing staff to call EMS for emergency transport to the Emergency Department (ED). Interviews with staff revealed that CMA R was fatigued during her shift and had to splash water on her face to stay alert. Despite this, she continued to pass medications until the end of her shift. The facility's administrative and nursing staff were unaware of CMA R's fatigue until after the incident. The error was reported to R1's healthcare provider, who advised monitoring R1's vital signs every two hours. However, due to the rapid decline in R1's condition, emergency medical intervention was required.
Removal Plan
- the facility suspended CMA R.
- Licensed Nurses (LN) and Certified Medication Aides (CMA) were provided education related to Medication Administration.
- Licensed Nurse (LN) and Certified Medication Aides (CMA) completed a Medication Administration check-off observed by Administrative Nurse A.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to maintain and dispose of garbage and refuse properly, leading to unsanitary conditions that could attract pests. During an initial tour, it was observed that two out of four compartments of the dumpster were open, exposing trash and garbage. Additionally, discarded building supplies were found surrounding the dumpster, with grass growing over the edges. Dietary Staff BB confirmed these findings and stated that the facility staff should keep all dumpster lids closed to prevent pest harborage. On a subsequent environmental tour, it was noted that the dumpster lacked one lid, further exposing trash and garbage. The Housekeeping and Maintenance Director U and Consultant GG acknowledged the issue, noting that the trash company had replaced the dumpster approximately two weeks prior. The facility did not have a policy in place to address the proper disposal and containment of garbage and refuse.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility did not accurately report 24-hour per day Licensed Nurse (LN) coverage on 12 dates between July 1, 2023, and September 30, 2023, and on 10 dates between January 1, 2024, and March 31, 2024. The Payroll Base Journal (PBJ) Staffing Data Report for these periods revealed gaps in LN coverage for 24 hours a day, seven days a week, on specified dates. This discrepancy was identified during a review of the PBJ Staffing Data Report for the fiscal year quarters in question. An interview with Administrative Staff A indicated that, to their knowledge, the PBJ was submitted correctly, and they believed that the licensed nurses working on weekends did not leave the facility or take lunch breaks, thus ensuring 24-hour coverage. However, the facility's policy for PBJ Reporting Procedure, which was undated, required staff to report PBJ hours to CMS quarterly, including data from Time Tracker, an electronic method for recording staff time, and agency staff. Despite these procedures, the facility failed to meet the CMS requirements for accurate staffing data submission.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility staff failed to report an allegation of verbal abuse involving a resident, identified as R4, who was called 'lazy' by a Certified Nurse's Aide (CNA O) in the presence of other residents. This incident occurred in the dining room, where CNA O was observed yelling at R4 and telling him he could push himself to his room. The event was witnessed by Certified Medication Aide (CMA R) and another Certified Nurse's Aide (CNA N), but it was not reported to the facility management until nine days later when CNA N resigned and disclosed the incident. R4, a resident with multiple health conditions including diabetes, heart failure, depression, and morbid obesity, required assistance with activities of daily living and used a wheelchair. Despite being cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, R4 did not recall the incident when interviewed later. The facility's policy mandates that any occurrence or suspected occurrence of neglect or abuse must be promptly reported to management, which did not happen in this case. The failure to report the verbal abuse immediately prevented the facility from taking timely action to protect the residents. The incident was only addressed after the facility was informed, leading to the suspension and eventual termination of CNA O. The delay in reporting the abuse was acknowledged by the facility's administrative staff, who confirmed that the staff did not follow the required protocol for reporting such incidents.
Failure to Investigate and Prevent Skin Tear in Resident
Penalty
Summary
The facility failed to conduct a thorough investigation into the causes and contributing factors of a skin tear experienced by a resident, identified as R18. The resident, who has severe cognitive impairment due to dementia and other health issues, was at risk for skin tears and required substantial assistance for daily activities. Despite these needs, the facility did not identify the cause of the skin tear or implement immediate interventions to prevent further injury. Observations revealed that the resident had a skin tear on the back of his right hand, which was treated with steri-strips and a foam dressing, but there was no documentation of the cause or preventive measures. The facility's lack of a policy for root cause analysis of skin tears contributed to the deficiency. Staff observations noted that the resident would hit his hand against walls and doorways while moving independently, yet no immediate intervention was documented to address this behavior. The administrative nurse confirmed the absence of a thorough investigation and immediate intervention, highlighting a gap in the facility's response to the resident's injury.
Failure to Maintain Pressure-Relieving Device for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a pressure-relieving device was in working order for a resident with a stage two sacral pressure ulcer. The resident, who had a history of diabetes, polyneuropathy, venous ulcers, and a stage two pressure ulcer, was assessed as having normal cognitive function and required partial assistance for transfers. Despite being assessed as not at risk for pressure ulcer development initially, the resident developed a stage two pressure ulcer and was provided with a pressure-reducing device for his chair and bed. The care plan included instructions for using a low air loss mattress and a cushion in the resident's chair, as well as specific wound care instructions. During an observation, it was noted that the resident was seated on two cushions in his recliner, and upon further inspection, it was found that the cushion contained multiple areas of malfunctioning air cells and was deflated. The administrative nurse, who was preparing to change the resident's dressing, was unaware of the deflated cushion until the observation and proceeded to replace it with a foam cushion. The facility's policy on therapeutic support surfaces required staff to consider chair seat cushions for residents in a sitting position, but the facility failed to monitor the status of the resident's cushion to ensure it was functioning optimally to provide pressure reduction.
Failure to Ensure Safe Transfer Due to Broken Equipment
Penalty
Summary
The facility failed to ensure a safe transfer for Resident 18, who has severe cognitive impairment and requires maximum assistance for transfers, by not using the safety belt on a sit to stand lift. The resident, diagnosed with dementia, dizziness, and hypertension, was at risk for falls and required two staff members for transfers. On the day of the incident, staff used a sit to stand lift with a broken safety belt, which had been in disrepair for over a week. Despite the equipment's condition, staff continued to use it without reporting the issue to the maintenance department. The facility's policy mandates that equipment in need of repair should be communicated to the environmental services department, and the safety belt should be used to ensure resident safety during transfers. However, the staff did not report the broken safety belt until the day of the incident, and the lift was used without the necessary safety precautions. This oversight led to a deficiency in providing a safe environment for the resident's care, as the facility did not adhere to its own policies regarding equipment maintenance and resident safety during transfers.
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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 Parsons
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elmhaven East | 2.1 mi | — | 0 | 0 |
| Good Samaritan Society - Parsons | 2.8 mi | — | 0 | 0 |
| Prairie Mission Retirement Village | 13.8 mi | — | 0 | 0 |
| Oswego Operator, Llc | 16.1 mi | — | 14 | 0 |
| Advena Living Of Cherryvale | 16.1 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.