Parkway Hills Nursing & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure treatment orders were obtained and followed for a surgical foot wound on one of two residents reviewed for wound care (Resident 1). This failure had the potential to result in infection or other wound complications.

Inspectors wroteBased on interview and record review, the facility failed to permit a resident to return to the facility after a hospitalization for one of two sampled residents (1). As a result, Resident 1 had a delayed stay in the hospital while waiting for alternate placement.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Dietary Manager (DM) had the required education or experience to effectively manage the Food Service department. This failure had the potential to place 52 residents at risk for foodborne illness. Cross reference: F806, F812, F813Findings: An interview was conducted with the DM on 9/22/25 at 9:45 A.M. The DM stated she had been employed as the DM for approximately 18 months. The DM stated she did not have a degree in food service management, or a Certified Dietary Manager (CDM) credential. The DM stated she did not have experience as a food service manager from any other facility. The DM stated she had been promoted into her current job by a previous manager. A record review of the DM's employee file was conducted on 9/22/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three residents reviewed for oxygen therapy had:Oxygen saturation levels (the amount of oxygen in the blood) routinely monitored and documented (Resident 3), and,A physician's order for oxygen therapy was obtained prior to administration (Resident 7). These failures had the potential for Residents 3 and 7 to receive oxygen when it was not required, resulting in the possibility of dependency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure alternate food items were of equal nutritive value. This failure had the potential to place residents at risk for nutritional deficits.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen sanitation and proper food storage was implemented in a manner that lessened the risk for foodborne illness when: 1. Food preparation areas, food storage containers and a tabletop can opener were visibly dirty, 2. Food in the kitchen was not labeled with opened date, use by date, or dispose date,3. Foods in the storeroom were not labeled with opened date or use by date, and4. Overhead light fixtures in the kitchen were rusted and dirty. These failures had the potential to cause foodborne illness to a population of 52 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the interdisciplinary team (IDT, a group of healthcare professionals from different disciplines involved in providing care to the residents) assessed and documented self-administration of medications kept at bedside was clinically appropriate for one of 15 sampled residents (Resident 29). This failure had the potential for Resident 29 to experience negative health outcomes, including increased risk of infections and not to receive the full therapeutic benefits of his medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive resident-centered care plan (detailed plan with information about a patient's treatment, goal, and interventions) was implemented for one of two sampled residents (Resident 8) reviewed for pain management. This failure had the potential to affect resident's care needs. Cross Reference F 697.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a pain medication was available for one of two residents reviewed for pain management (Resident 8). This failure had the potential to cause the resident unnecessary pain, negatively affecting the resident's quality of life. Cross Reference to F 656.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services when:1. Random controlled medication (medications with a high abuse potential) use audit for five of six sampled residents (Residents 6, 19, 26, 27 and 52) indicated medications were signed out of the controlled drug record (CDR, count sheet used to track controlled medications), but were not documented on the Medication Administration Record (MAR - section of the medical record where all medications given to the resident are recorded to ensure patient safety) to indicate they were administered to the residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 10.71% when three medication errors occurred out of 28 opportunities during the medication administration for one of seven randomly observed residents (Resident 26). This failure had the potential for Resident 26 not to get the full therapeutic benefit of his medications or to experience negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication was stored under proper temperature controls in one of one Medication Rooms. This failure had the potential to negatively alter the drug's stability, physical properties (such as consistency) and effectiveness, which could result in adverse resident outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident food brought into the facility from outside sources was stored appropriately, and procedures were in place for safe reheating of foods. This failure had the potential to result in pest control concerns, as well as foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurately documented records when the wrong blood pressure (BP) reading was recorded on the Medication Administration Record (MAR, an official legal document that has a complete and accurate record of all medications administered to a resident to ensure patient safety) of one out of five sampled residents (Resident 9). This failure resulted in inaccurate documentation in Resident 9's medical records.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement proper infection control practices in one of 15 sampled residents (Resident 26). This occurred when Certified Nursing Assistant (CNA) 1 and CNA 2 did not wear proper personal protective equipment (PPE, clothing or equipment, such as gowns, gloves and masks, designed to prevent the spread of infections) while caring for Resident 26, who was on enhanced barrier precautions (EBP, infection control practices designed to prevent the spread of multidrug resistant organisms [MDROs, germs that cannot be killed or inactivated by medications] in nursing homes). This failure had the potential to put residents, staff, and visitors at risk for infections due to cross-contamination.

Inspectors wroteBased on observation and review of the Client Accommodations Analysis (document with measurements of the square footage of the useable living space of individual resident rooms and approved capacities), the facility failed to provide the minimum of 80 square feet (sq. ft.) per resident in 4 of 28 resident rooms. This failure had the potential for residents in rooms 2, 4, 6, and 21 to feel cramped and uncomfortable.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and homelike environment for residents residing in the facility when: 1. Hallway floors were taped and with missing floorings, 2. A handrail was observed loose and wobbly. This failure had the potential for residents to trip, fall and sustain injury.

Inspectors wroteBased on interview and record review the facility failed to staff a Registered Nurse (RN) for at least 8 hours a day for 18 days from January 1, 2024 through March 31 of 2024. This failure had the potential for residents and staff to receive inadequate supervision and for residents to not receive an appropriate quality of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to prevent medication errors of less than 5% for three of eight sampled residents (Resident 37, Resident 31, and Resident 33) during medication pass observation with three licensed nurses (LN 1, LN 2 and LN 3) when: 1. LN 1 administered medications to Resident 37's gastronomy tube (G-tube: a surgical opening on the abdomen for nutritional and/or medication administration) omitting one medication to be administered and the full dose of medications administered (eight medication errors) . 2. LN 2 did not administer Resident 31's morning medications (9:00 A.M.) as scheduled for more than three hours (nine medication errors). 3. LN 3 did not administer Resident 33's Januvia (oral medication that lowers blood sugar) as scheduled due to medication not available in medication cart (one medication error). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of eight sampled residents (Resident 37, Resident 31, and Resident 33) were free from significant medication errors when: 1. LN 1 administered medications to Resident 37's gastronomy tube (G-tube: a surgical opening on the abdomen for nutritional and/or medication administration) omitting one medication to be administered and the full dose of medications administered. 2. LN 2 did not administer Resident 31's morning medications (9:00 A.M.) as scheduled for more than 3 hours. 3. LN 3 did not administer Resident 33's Januvia (oral medication that lowers blood sugar) as scheduled due to medication not available in medication cart. As a result, Resident 37, Resident 31 and Resident 33 had the potential for serious health complications to cause discomfort and/or jeopardizes his or her health and safety. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure kitchen staff (dishwashers) had the competency to use, operate, document and check the water temperatures of two low temperature dishwashers. This failure increased the risk of food borne illness being transmitted via dirty dishware. On 8/21/24 at 8 A.M., a concurrent observation of low temperature dishwasher, interview with Dishwasher (DW) 11, and record review of Dish Machine Temperature Log was conducted. DW 11 stated that the process for washing the dishes was to spray the dishes in sink to rinse off food, place the dishes in the rack in the machine, turn on the machine to do it's rinse, then do a check for chlorine after the rinse cycle. DW 11 was observed taking chlorine sample at water exit site from the machine, not directly on dishes that had just been rinsed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served to all residents was in a palatable, flavorful manner that maintained the nutritional value of the menu items served. This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 55.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: 1. Soy sauce and teriyaki glaze were stored per manufacturer's recommendation, 2. The low temperature dishwasher reached appropriate rinsing temperature for sanitization of dishware. These failures increased the chances of residents getting foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accurately code the Minimum Data Set (MDS: a nursing assessment tool) for one of five residents (Resident 31) reviewed for vaccination status. As a result, the facility sent Resident 31's MDS to the federal database with inaccurate vaccination status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update a resident centered care plan for one resident (Resident 6) with a continuous positive airway pressure (CPAP - a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) machine reviewed for care plans. This deficient practice had the potential for Resident 6 to not receive a resident centered and appropriate care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 9 residents (Resident 43 and Resident 30) reviewed for activities of daily living (ADL-basic tasks of everyday life) received assistance with nail care. This deficient practice had the potential to affect the residents' dignity, cause infection from the debris under the fingernails and cause injury from having long, jagged fingernails.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order for the settings of a continuous positive airway pressure (CPAP-a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) was ordered for one (Resident 6) of three residents reviewed for respiratory care. This deficient practice had the potential for Resident 6 to receive inappropriate care and treatment which could lead to a decline in Resident 6's respiratory status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident medications (Resident 1) were secured and locked during a medication storage inspection. This failure had the potential for medication misuse, divergence (another person taking medications or medications used wrongfully), and unauthorized person to have access to the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain infection control procedures for three (Resident 27, Resident 34 and Resident 6) of 17 residents reviewed for infection control when: 1. Oxygen tubing was not changed weekly for two residents (Resident 27 & 34) per policy and procedure . 2. CPAP mask for Resident 6 was not stored properly. These deficient practices had the potential for residents to transmit infectious microorganisms and increase the risk of infection for residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer and/or administer an updated pneumococcal vaccine for two of five residents (Resident 31 and Resident 37) reviewed for immunization. These failures increased the risk to compromise the health and well-being of Resident 31 and Resident 37 with respiratory infections and other complications associated with pneumonia (a respiratory infection caused by bacteria, virus or fungi that causes the lungs to be inflamed making it hard for oxygen to circulate in the blood stream that can cause discomfort and difficult to breath).

Inspectors wroteBased on observation and review of the Client Accommodations Analysis (document with measurements of the square footage of the useable living space of individual resident rooms and approved capacities), the facility failed to provide the minimum of 80 square feet (sq. ft.) per resident in 4 of 28 resident rooms.

Inspectors wroteBased on observation and interview, the facility failed to equip resident rooms with curtains to ensure complete visual privacy for one of two sampled residents (1). As a result, there was the risk of facility residents observing Resident 1 while she received personal care.

Inspectors wroteBased on interview and record review, the facility failed to ensure neuro checks (used to assess an individual's neurological functions and level of consciousness) was completed after a resident ' s (Resident 1) fall for one of three sampled residents. This failure had the potential to place Resident 1's health at risk.

Inspectors wroteBased on interview and record review, the facility failed to complete a breathing treatment as ordered for two of two sampled residents (1, 2). As a result, the residents had a risk of decreased lung function.

Inspectors wroteBased on interview and record review, the facility failed to have a registered nurse (RN) on duty for eight hours per day on 21 of 31 sampled days. As a result, there was a risk of decreased quality of care and facility and resident oversight.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe and home-like environment when; A. Ten of 54 resident rooms (Rooms 5, 6A, 6B, 16, 17, 18, 20, 27, 28A, and 28B) had power strips that were not UL (Underwriters Laboratories, nationally recognized standards for safety) certified and had multiple electrical cords plugged into power strips that were not fastened to the wall or floor, B. Six of 24 resident rooms had a broken window ( Rooms 14, 16, 21, 24, 25, and 26). C. Six of 24 rooms had temperature levels that were not within a comfortable range (Rooms 12, 14, 16, 25, 26, and 27). D. One resident (36) had a space heater that was not UL certified, and E. The facility did not have a permanent generator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and consistently maintain a QAPI plan when: A. Current Infection control practice standards were not followed during medication administration and staff screening for COVID-19 (a highly contagious respiratory disease that could affect the entire body); B. Resident room windows were broken and not repaired, non certified for safe use power extension cords were used, and facility generator did not function during power outage; C. Facility staffing coverage not monitored and; D. Two emergency medication kits were not properly secured and accounted for. This failure had the potential to affect the safety, quality of life and care of all the residents in the facility. See F880, F584, F725, and F761.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain proper infection control practices based on current standards when: A. Two staff members (CNA 11, CNA12) did not screen for COVID-19 prior to clocking in for work; B. Staff did not properly sanitize medical equipment and did not perform hand hygiene between residents during medication administration (LN 19, LN 41, LN 44). These failures to ensure proper infection control practices based on current standards had the potential to spread infection in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure six medication consents that required a physician's signature were signed for one of five sampled residents (16). As a result Resident 16 received medication without proper education.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clarify a Physician's Order for Life Sustaining Treatment (POLST) for one of two sampled residents (19). This failure had the potential for residents to receive inaccurate life sustaining measures during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and clarify with the physician the use of physical restraint (any device that the individual cannot remove easily which restricts freedom of a person's bodily movement) for one of one sampled resident (23). As a result, Resident 23 complained of hand and shoulder pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to reevaluate the use of a hand mitten physical restraint (any device that the individual cannot remove easily which restricts freedom of a person's bodily movement) for one of one sampled resident (23). Failure to reassess the need of a physical restraint have the potential for residents to be placed for injury and affect their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident centered care plan for antipsychotic medications (medication to treat mental illness) for two of five sampled residents (2, 32). This failure had the potential for the staff not to recognize behavioral changes and possible side/adverse effects in Resident 2 and 32.

Inspectors wroteBased on interview and closed record reviews, the facility failed to develop a discharge plan for one of two sampled residents (49). Resident 49 left the facility against medical advice (AMA- leaving the facility without a doctor's approval) thirteen days after his admission date. This failure had the potential for Resident 49 to not receive appropriate coordination of care upon discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate a scheduled hospice visit and plan of care for one of two hospice residents reviewed for hospice care (39). This failure had the potential for miscommunication among health care givers.

Inspectors wroteBased on interview, and record review, the facility failed to ensure there was enough staff coverage to meet the residents' needs. This failure had the potential to affect the quality of care and life of all the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a medication that required titration(gradually lowering a drug's dosage over a prolonged period) as ordered by a physician for one of three sampled residents (2). As a result Resident 2 did not receive the full benefits of the drug treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two emergency kits (Ekits) were locked, secured, and accounted for. Failure to secure Ekits had the potential for drug diversion and inappropriate medication use.

Inspectors wroteBased on observation, interview, and review of facility documents the facility failed to ensure food was stored in accordance with professional standards of food service safety when: A. multiple food items were in the refrigerator or freezer with no dates and not properly sealed; B. staff's personal items were stored in the kitchen next to the refrigerator; C. a window sill in the food storage room was not clean; and D. two dented cans. These failures to ensure effective food and nutrition service operations may result in placing residents at risk for food borne illness and the growth of harmful organisms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate physician's progress notes for one of one sampled resident (23). This failure had the potential for Resident 23 to receive inaccurate treatments and wrong medical information.

Inspectors wroteBased on observation and review of the Client Accommodations Analysis (document with measurements of the square footage of the useable living space of individual resident rooms and approved capacities), the facility failed to provide the minimum of 80 square feet (sq. ft.) per resident in 4 of 28 resident rooms.