Parkview Care Center

In the surveyor’s words

From the most serious findings on record at Parkview Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jul 22, 2025

  Based on closed medical record review, staff interviews, Emergency Medical Services (EMS) staff interview, Coroner investigator interview, review of an EMS run report, review of hospital and emergency room (ER) documentation, review of an electronic mail (e-mail) document, review of a Coroner's report and Coroner's Report of Death document, and review of facility policies, the facility failed to ensure a resident (#50), with known swallowing issues, was provided with appropriate and timely treatment and services when the resident was assessed with changes in condition. […]

• Immediate jeopardy, isolatedF600May 20, 2024

  Based on observation, review of medical records, review of self-reported incidents (SRI), review of witness statements, interviews with staff, residents, and family, and policy review, the facility failed to ensure one cognitively impaired resident (#03) was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for serious physical, mental and/or psychosocial negative outcomes for two residents (#03 and #21) when the facility failed to recognize and respond to Resident #02's increased sexual behavior. State tested Nursing Assistant (STNA) #112 reported on 04/20/24, Resident #02 had pulled his genitalia out in front of Resident #03. STNA #112 reported the incident to a nurse. […]

• Actual harm, isolatedF686Jan 13, 2026

  Based on medical record review, observation, staff interview, facility policy review, and manufacturer user manual, the facility failed to ensure pressure relieving interventions were implemented to promote healing and prevent the development of pressure ulcers. Actual Harm occurred when Resident #02 was placed on a faulty alternating air mattress without standard wound or equipment assessment which resulted in the deterioration of an existing stage IV pressure ulcer (full-thickness loss with exposed bone/muscle/tendon) and the development of three in-house acquired unstageable (obscured by sloth/eschar) deep tissue injuries (purple/maroon discoloration, intact or blistered skin) to the back and buttock. This affected one (#02) of four residents reviewed for pressure ulcers. […]

• No harm, potential for more than minimal, widespreadF606Jan 13, 2026

  Based on employee personnel file review, review of the facility criminal background log, review of the facility daily timecard activity, staff interview, and policy review, the facility failed to ensure nursing staff with disqualifying legal convictions were not employed by the facility. This affected all 31 residents residing in the facility.Findings include:Review of the personnel file revealed Licensed Practical Nurse (LPN) #200 was hired on 10/28/25.Review of the facility criminal background log noted LPN #200's criminal background investigation was submitted on 10/27/25 and returned on 11/20/25.According to facility daily timecard activity noted LPN #200 worked a scheduled shift on 01/06/26 between 6:53 A.M. […]

• No harm, potential for more than minimal, widespreadF880Mar 13, 2025

  Based on review of a the facility water management plan, staff interview, review of the Centers for Disease Control and Prevention (CDC) website, and policy review, the facility failed to implement a complete water management program to prevent the growth of Legionella bacteria and failed to wear gloves during administration of an injected medication. This had the potential to affect all 34 residents residing in the facility. The census was 34. Findings include: 1. Review of the facility the facility's water management plan lacked any information about how the facility would intervene when control measures were not met and possible contamination with Legionella bacteria was suspected or address ongoing monitoring of the plan's effectiveness. […]