Resident #67 told inspectors during a March 11 interview that the bed alarm "went off frequently" and he voiced, "I hate it." When the alarm sounded, he reported stopping his movement "so it will stop alarming."
The facility's own restraint policy defines physical restraints as "any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement."
Certified Nurse Assistant #6 confirmed she had observed Resident #67 stop moving when the alarm sounded "as he did not want it to continue." She believed she reported this behavior to nursing staff.
But no restraint assessments were completed for either alarm device. The Medicare Nurse confirmed that if the resident stated he stops moving to make the alarm stop and staff observed this behavior, "the alarms would be considered a restraint."
The Director of Nursing told inspectors she was unaware that Resident #67 had voiced his dislike for the alarm or that it caused him to stop moving. While the resident had a physician's order for an alarm pad on his wheelchair dated October 15, 2024, no order existed for the bed alarm pad.
"She did not know when or by whom the bed alarm pad was placed," inspectors wrote.
The Director of Nursing confirmed that if the resident expressed distress about the alarm and staff verified his behavior of stopping movement to silence it, "both alarm devices would be considered restraints."
Resident #67 was admitted with repeated falls and scored a 7 on cognitive testing, indicating severe impairment.
The restraint violation was one of several care failures inspectors documented at Parkway Health & Rehab during a March 13 survey.
A dialysis patient received the wrong fluid restriction for three weeks after a registered dietitian's recommendations were "misplaced" by nursing staff. Resident #12, admitted in December with end-stage kidney disease, was supposed to receive 1,200 milliliters of fluid daily according to his dialysis physician.
But facility records showed he was on a 1,500-milliliter restriction instead.
On February 18, the facility's registered dietitian spoke with the dialysis center's dietitian about the resident "having issues with fluid overload." The dialysis dietitian stated "that fluid restriction for resident is 1000 ml H20, however online orders show 1500 ml H20."
The facility dietitian recommended consulting the physician for clarification and changing the tube feeding formula to reduce fluid content. Her note stated the new feeding would provide "1125 milliliters free H20" compared to the previous formula.
None of the recommendations were implemented.
The facility dietitian told inspectors she gave her recommendations to the Director of Nursing or Assistant Director of Nursing on February 18. The Director of Nursing confirmed the recommendations "should have been put into place" but said they "must have been misplaced because she was unable to locate it."
The Director of Nursing acknowledged "the physician should have been made aware as the resident had had a delay getting the care."
The dialysis center's registered dietitian told inspectors she faxed a 1,200-milliliter fluid restriction order to the facility on February 20. Records show this order was not implemented until March 7.
Resident #12 also failed to receive his ordered hand splint for contractures. Inspectors observed him on March 11 and March 12 without the device, despite orders requiring it be worn 4-6 hours daily.
Licensed Practical Nurse #3 confirmed she signed off on the medication record as "administered" without ensuring the splint was actually applied. "She admitted she did not go back to ensure it was applied," inspectors wrote.
When asked about the missing splint, Certified Nurse Assistant #1 said, "I guess someone took it to laundry because he didn't have it." She confirmed she did not look for it.
The Assistant Director of Nursing told inspectors that "failing to apply the splint could cause worsening contractures."
Personal hygiene failures affected multiple residents. Inspectors found four men with lengthy facial hair who said they wanted to be shaved but hadn't been asked.
Resident #1 had facial hair approximately three-quarters of an inch long on his chin, face and neck. His hair was "unkempt and thick." He told inspectors, "The barber has not been here in quite some time. I would like to have a haircut and be shaved."
He said "no one had asked him if he wanted to be shaved or have a haircut, and it's been a very long time." Records showed his last haircut was October 8, 2024.
Resident #61 had facial hair approximately one and a half inches long and hair that was "unkempt, long, and greasy." He stated "it's been a long time since he had been shaved and had a haircut."
His assigned aide confirmed he "needed to be shaved and have his hair washed and cut" and said "he was looking rough." She wasn't sure how long it had been since he received grooming care.
Resident #34 appeared "unshaven" with hair that was "oily with visible white flakes around the scalp edges." He wanted to be shaved and have his hair washed but "was unable to recall the last time he received such care."
Resident #67's "face and hair appeared oily with long unkempt facial hair." He said "he had not been shaved in a while and could not remember when his hair was last washed."
Documentation showed only two days of personal hygiene care for Resident #67 between February 27 and March 12.
The Director of Nursing confirmed "all residents should receive personal hygiene daily and as needed" and acknowledged that "a lack of personal hygiene could lead to potential skin issues."
A Vietnam veteran with Post-Traumatic Stress Disorder lacked a care plan addressing his specific triggers, despite staff knowing what caused his distress.
Resident #41's care plan noted his PTSD diagnosis was "related to killing other humans with a machine gun in combat" and that he "has experienced other trauma such as death of close family, being assaulted in lifetime." But the plan included no trigger-specific interventions.
The Director of Nursing confirmed the resident's triggers were "being awakened in the middle of the night by staff knocking on the door and entering the room." She acknowledged he "did not have a PTSD care plan that addressed trigger-specific interventions, so therefore the staff were not made aware so that they could try and prevent re-traumatization."
The Social Worker admitted she "didn't know what Resident #41's triggers were" and had "never discussed his PTSD or triggers with the him."
Inspectors also found assessment errors. One resident taking the antiplatelet medication Plavix was incorrectly coded as receiving an anticoagulant medication on his annual assessment. The Medicare Nurse confirmed "Section N was coded wrong" and "the antiplatelet box should have been marked."
The facility received citations for failing to ensure accurate assessments, develop complete care plans, provide adequate activities of daily living care, maintain range of motion, ensure freedom from restraints, and provide proper nutrition and hydration.
Several violations represented repeat findings from the facility's previous annual survey, leading inspectors to increase severity ratings due to the pattern of non-compliance.
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.