Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Parkside Lutheran Home during CMS and state inspections, most recent first.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling devices, such as feeding tubes and urinary catheters, and did not make PPE readily available. Additionally, staff did not consistently follow catheter care and hand hygiene protocols, as observed with a resident's urinary drainage bag being placed on the floor and CNAs not sanitizing hands after providing care. These actions violated the facility's infection control policies.
The facility failed to ensure call lights were within reach for a resident with Alzheimer's and mobility issues, risking falls and injury. A resident expressed concerns about staff interactions, and an observation confirmed the call light was out of reach while the resident needed assistance. An administrative nurse acknowledged the expectation for staff to keep call lights accessible.
A facility failed to provide a written notice of transfer to a resident or their representative when the resident was transferred to a hospital. The medical record lacked documentation of the notice, and an administrative staff member confirmed that providing such notice is expected when a resident is hospitalized.
A facility failed to provide a written bed hold notice to a resident or their representative during a hospital transfer. The deficiency was identified through a review of medical records and staff interviews, revealing a lack of documentation for the notice. An administrative staff member confirmed the expectation for staff to issue a bed hold notice whenever a resident is out overnight.
The facility failed to update care plans for three residents to reflect their current medication use, including a diuretic, an anticoagulant, and an antidepressant, as identified through record reviews and staff interviews.
A facility failed to follow professional standards by not transcribing a physician's order for a resident's foley catheter after the resident returned from the hospital. The omission was confirmed by an administrative nurse, who acknowledged that the order was missed during transcription.
The facility failed to properly use gait belts during stand-pivot transfers, as observed with two residents requiring assistance. One resident, with Alzheimer's and a history of femur fracture, was assisted by a CNA who pulled upward on her pants instead of using the gait belt correctly. Another resident, with severe vascular dementia and mobility issues, was similarly assisted by two CNAs. The facility's policy mandates the use of gait belts for safe transfers.
A facility failed to assess a resident with PTSD and identify known triggers, which are essential for trauma-informed care. The resident's medical record lacked an assessment of past traumas, and the care plan did not include known triggers or interventions to prevent re-traumatization. An administrative nurse confirmed the staff's failure to assess and implement necessary interventions. Additionally, the facility could not provide a policy addressing PTSD.
A facility failed to conduct the required Abnormal Involuntary Movement Scale (AIMS) screenings for a resident receiving the antipsychotic medication Abilify, as per their policy. The policy requires AIMS screenings every six months to monitor for tardive dyskinesia, but the resident's medical record lacked the necessary reassessments. An administrative nurse confirmed the expectation for biannual reassessments, highlighting a lapse in adherence to the facility's guidelines.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for several residents, particularly in the application of Enhanced Barrier Precautions (EBP). Resident #11, who had multiple wounds requiring dressing changes, was not placed on EBP, and personal protective equipment (PPE) was not made readily available to staff. Similarly, Resident #90, with a feeding tube, and Resident #139, with a urinary catheter, were not placed on EBP, and PPE was not accessible, despite the facility's policy requiring such measures for residents with indwelling medical devices. In addition to the lack of EBP, the facility's staff did not consistently follow proper catheter care and hand hygiene protocols. Observations revealed that CNAs handling Resident #139's urinary drainage bag failed to keep it off the floor and did not perform hand hygiene after handling soiled equipment. The CNA also reconnected the drainage tube without sanitizing it after it had been dropped on the floor. These actions were contrary to the facility's policies on catheter care and hand hygiene. Further deficiencies were noted in hand hygiene practices during resident care. CNAs assisting Residents #14 and #25 with toileting and peri-care did not perform hand hygiene after removing gloves and before proceeding with other tasks. This failure to sanitize hands after providing care and before exiting the room or performing additional tasks was a direct violation of the facility's hand hygiene policy, which emphasizes hand hygiene as a primary means of preventing infection transmission.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure care and services were provided according to accepted standards of quality for a resident observed during stand-pivot transfers. Specifically, the staff did not place call lights within the resident's reach, which placed residents at risk for falls and/or injury. During interviews, a resident expressed concerns about the staff's interaction with her roommate, who frequently asked to go to the bathroom but often found the call light out of reach. An observation confirmed that the resident was sitting in her wheelchair with the call light attached to the bed, out of reach, while she expressed a need to use the bathroom. The resident's medical record indicated diagnoses of Alzheimer's disease, dementia, osteoarthritis, and a history of left femur fracture, with a care plan requiring assistance for locomotion and transfers. An administrative nurse confirmed the expectation that staff should ensure call lights are within reach of residents.
Failure to Provide Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident or their representative, which is a requirement when a resident is transferred to a hospital. This deficiency was identified during a review of the medical records for a resident who was transferred to a hospital. The medical record did not contain documentation that the facility had provided the necessary written notice of transfer. An administrative staff member confirmed during an interview that it is expected for staff to provide such notice whenever a resident is hospitalized.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written notice of bed hold to a resident or their representative during a hospital transfer. This deficiency was identified during a review of the medical records and staff interviews. Specifically, the medical record of a resident who was transferred to a hospital lacked documentation that a written bed hold notice was provided. An administrative staff member confirmed that it is expected for staff to provide such a notice whenever a resident is out of the facility overnight.
Failure to Update Care Plans for Medication Use
Penalty
Summary
The facility failed to review and revise the comprehensive care plans to reflect the current status for three residents. Resident #5's care plan did not address the use of a diuretic medication, despite the quarterly Minimum Data Set (MDS) and current physician's orders indicating that the resident received Lasix daily. Similarly, Resident #7's care plan failed to include the use of an anticoagulant medication, even though the MDS and physician's orders showed that the resident was on Eliquis daily. Additionally, Resident #30's care plan did not reflect the use of an antidepressant medication, despite the MDS and physician's orders indicating daily administration of Mirtazapine. These omissions in the care plans were identified through observation, record review, and staff interviews, highlighting a failure in the facility's process to ensure that care plans are updated to communicate residents' current medication needs effectively.
Failure to Transcribe Physician's Order for Catheter
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding physician's orders for a resident with a catheter. During the survey, it was observed that the resident had a catheter bag under her wheelchair. Upon reviewing the resident's medical record, it was found that after returning from the hospital, the current physician's orders did not include an order for the resident's foley catheter. An administrative nurse confirmed that the staff failed to enter the order for the catheter, indicating that the order was missed during transcription when the resident returned from the hospital.
Failure to Properly Utilize Gait Belts During Transfers
Penalty
Summary
The facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury during stand-pivot transfers for one of the sampled residents. Observations revealed that a certified nurse aide (CNA) placed a gait belt around a resident's waist, tightened it, locked the brakes on the wheelchair, and assisted the resident to stand by pulling upward on the back of her pants. This action was contrary to the facility's policy, which mandates the use of a gait belt for all residents requiring assistance with transfers and ambulation to ensure safety from injury. The resident involved had a medical history that included Alzheimer's disease, dementia, osteoarthritis, and a history of left femur fracture, and required assistance with transfers as identified in her care plan. Another observation showed two CNAs assisting another resident with toileting, where one CNA placed a gait belt around the resident's waist and assisted her to stand by pulling upward on the back of her pants. This resident had diagnoses including abnormalities of gait/mobility, disorders of bone density/structure, right hemiplegia following a cerebral infarction, and severe vascular dementia, and also required assistance with transfers. An administrative nurse confirmed that staff were expected to utilize a gait belt when transferring residents.
Failure to Assess PTSD and Identify Triggers
Penalty
Summary
The facility failed to assess a resident with a history of Post-Traumatic Stress Disorder (PTSD) and identify known triggers, which is crucial for providing trauma-informed care. The medical record of the resident, who has a complex psychiatric history including PTSD, lacked an assessment addressing past traumas. Additionally, the care plan did not identify known triggers or list interventions to prevent re-traumatization. An administrative nurse confirmed that staff did not assess residents with PTSD, identify their known triggers, or implement interventions to prevent re-traumatization. Furthermore, the facility was unable to provide a policy addressing PTSD.
Failure to Conduct Required AIMS Screenings for Antipsychotic Medication
Penalty
Summary
The facility failed to manage and monitor a resident's drug regimen effectively, which is necessary to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility did not complete the required Abnormal Involuntary Movement Scale (AIMS) screenings for a resident receiving the antipsychotic medication Abilify, which is used to treat major depression and psychosis. The facility's policy mandates that AIMS screenings be conducted every six months for residents on neuroleptic medications to assess for tardive dyskinesia, an involuntary movement disorder. However, the medical record for the resident in question did not include the necessary reassessments for January 2024 and July 2024. During the survey, it was confirmed by an administrative nurse that the expectation was for staff to reassess any resident receiving antipsychotic medication every six months. Despite this policy, the facility failed to adhere to its own guidelines, as evidenced by the absence of the required AIMS screenings in the resident's medical record. This oversight could potentially lead to adverse reactions to the medication, such as tardive dyskinesia, although the report does not specify any such outcomes for the resident involved.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Dakota Veterans Home | 2.6 mi | — | 0 | 0 |
| Smp Health - Maryhill | 13.4 mi | — | 3 | 0 |
| Four Seasons Health Care Inc | 23.6 mi | — | 10 | 0 |
| Good Samaritan Society - Oakes | 28.2 mi | — | 11 | 1 |
| St Rose Care Center | 29.4 mi | — | 12 | 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.