Resident 12 arrived at Parkway Health & Rehab in December 2024 weighing 115.3 pounds. By early March, he had dropped to 112.6 pounds despite receiving tube feedings designed to help him gain weight. Federal inspectors found the facility failed to act on critical dietary changes that could have prevented his continued deterioration.
The registered dietitian spoke with the dialysis center's nutritionist on February 18 about the resident's mounting problems. He was losing weight and experiencing fluid overload during dialysis sessions. The dialysis specialist recommended reducing his daily fluid intake from 1,500 milliliters to 1,200 milliliters and switching to a more concentrated tube feeding formula.
"RD suggests changing TF to Nutren 2.0 in order to meet needs for weight gain/wound healing without having excess fluids to prevent overload," the dietitian wrote in her notes. She recommended consulting the physician immediately for fluid restriction clarification and changing medication flushes to use less water.
None of these recommendations were implemented.
The facility's Director of Nurses admitted during interviews that the recommendations "must have been misplaced" and confirmed they should have been put into place. She said she usually places dietitian recommendations in the physician's folder for review, but was unable to locate these critical changes.
Meanwhile, the resident's condition worsened. Dialysis records showed he was consistently 3 to 4 kilograms over his target weight before treatments. On March 10, just three days before the inspection, he was 4 kilograms (8.8 pounds) over his pre-dialysis weight. The goal was to stay within 1 to 2 kilograms of target weight.
The dialysis center's clinical director explained the severity of the situation. Being that far over target weight with excessive fluid "could result in elevated blood pressure" if proper dietary restrictions weren't followed.
Records revealed the dialysis center had already sent new orders to the nursing home on February 20, specifying the resident should follow a fluid-restricted diet limiting intake to 1,200 milliliters per day. But the facility's Director of Nurses said they never received this faxed physician order.
The resident's weight history told a stark story of decline. He entered the facility at 115.3 pounds on December 3. By January 3, he had dropped to 106.9 pounds. Though his weight fluctuated slightly upward in February, reaching 117.7 pounds, it fell again to 112.6 pounds by March 7.
The facility's own dietitian confirmed during a telephone interview that failure to act promptly on her recommendations "could place the resident at risk for continued fluid overload." She had last seen the resident on February 18, the day she made her urgent recommendations to nursing leadership.
The Director of Nurses acknowledged during a second interview that the resident's fluid volume status was "of high importance" and that the physician should have been made aware immediately. Instead, she said the nurse practitioner intended to review the recommendations during a planned visit "a couple of days later."
She confirmed the resident "had had a delay getting the care."
The resident suffered from hypertensive heart disease, chronic kidney disease with heart failure, and end-stage renal disease. His complex medical needs required precise coordination between the nursing home and dialysis center to prevent life-threatening complications.
Federal inspectors found additional problems throughout the facility during their March visit.
A Vietnam War veteran with post-traumatic stress disorder received no trauma-informed care despite having a documented diagnosis related to "killing other humans with a machine gun in combat." His care plan listed his PTSD but included no interventions for triggers or trauma-specific care.
The Director of Nurses knew the veteran's triggers included "being awakened in the middle of the night by staff knocking on the door and entering the room." But staff were never informed of these triggers or trained on interventions to prevent re-traumatization.
A certified nursing assistant assigned to the veteran said she "had no idea" he had PTSD. The social worker confirmed she knew about his diagnosis but had never discussed his triggers with him and didn't know what they were.
In another violation, inspectors found a resident with moderate cognitive impairment had medications sitting unsecured on his bedside table. Tums antacid and nasal spray remained accessible for days, despite facility policy requiring all medications to be locked in medication carts.
The resident told inspectors he needed the medicine for bad indigestion and threatened to leave if staff tried to remove it. His assigned nurse was unaware the medications were there, even though she administered all his other drugs directly.
The Assistant Director of Nurses confirmed the resident had not been evaluated for self-medication and was not authorized to keep drugs at his bedside. She noted that unsecured medications posed risks if the resident took too much or if other residents wandered into his room.
Kitchen staff violated food safety protocols during meal preparation. A dietary worker checked food temperatures without washing his hands first, then used the same dish cloth to wipe the thermometer probe between testing different foods, including raw hamburger patties and fresh vegetables.
The worker admitted this practice "could potentially make a resident sick due to cross-contamination from the dish towel to the food." The dietary manager confirmed staff should use disposable wipes to clean thermometer probes and perform hand hygiene before handling food.
Inspectors also found improper catheter care for a resident with a history of frequent urinary tract infections. Her catheter bag and tubing were observed lying on the floor, and staff cleaned her catheter using only water instead of the ordered soap and water regimen.
The nursing assistant performing the care acknowledged the catheter bag should not have been on the floor and said she avoided using soap because she didn't want to irritate the resident's skin. The Director of Nurses confirmed these practices increased infection risk.
The facility also submitted inaccurate staffing data to federal regulators, reporting excessively low weekend staffing during the first quarter of 2025. The Human Resources Director blamed the error on transitioning between payroll systems, saying "all of the nursing hours did not show up accurately."
The Administrator expressed confusion about the low staffing report, stating the facility was "adequately staffed during that time." Internal staffing records showed no weekend staffing problems during the period in question.
For the dialysis patient whose care triggered the inspection, the consequences of delayed treatment remained unresolved. His weight continued to fluctuate dangerously while critical dietary interventions sat unimplemented in a misplaced folder somewhere in the facility's administrative offices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkway Health & Rehab LLC from 2025-03-13 including all violations, facility responses, and corrective action plans.