Parkwood Skilled Nursing: Family Not Told of Wounds, Meds - MO
Inspectors cited Parkwood Skilled Nursing and Rehabilitation Center on November 6, 2025, following a complaint investigation. The deficiency centered on a single resident, confused since the day they arrived, who could not speak for themselves and had no one at the facility filling that gap.
The heel first appeared dark and soft on September 17. By October 11, just before 4 in the morning, it had opened. Inspectors noted slough in the wound bed and eschar around it. The wound measured 3 centimeters long and 7 centimeters wide. No one had documented notifying the resident's responsible party that the wound existed, that it had opened, or that it had grown.
The psychiatric medication trail was just as unbroken in its silence. On September 24, a physician ordered doxepin, used to treat depression. On October 6, a psychiatry nurse practitioner added Depakote Sprinkles, a mood stabilizer, prescribed three times daily. On October 13, hydroxyzine was added for restlessness and agitation. Three drugs, across three separate orders, over nearly a month. Inspectors found no documentation in the progress notes that the responsible party was ever contacted about any of them.
The psychiatry NP had evaluated the resident on October 4. Her notes described someone who did not know where they lived, who had been very irritable in the evenings, unable to sleep, hard to redirect. The resident was confused and usually not following the conversation. She attached the medication orders to her encounter note. What she did not do, according to the inspection record, was notify the family.
Nobody had.
The nurses interviewed during the inspection agreed on what should have happened. LPN C said the responsible party should be notified of any new wounds, treatments, and medications, and that the Charge Nurse, Nurse Manager, or Wound Nurse carries that responsibility. The documentation, she said, goes in the progress notes. LPN B said the same, adding that she wasn't sure whether it fell to the Charge Nurse or the psychiatry NP when a new psychiatric medication was ordered.
Nurse Manager A offered a detail that explained part of the breakdown. The psychiatry NP, she said, enters orders directly into the computer without alerting nursing staff. The only communication Nurse Manager A received from the October 4 evaluation was an emailed copy of the NP's notes. She acknowledged the family should have been notified about the wound and the new medications. She did not describe any system that would have caught the gap.
The Director of Nursing told inspectors she expected nursing staff to notify the responsible party of any changes in condition, wound status, or new medication orders, and expected that contact to be documented in the progress notes. The progress notes showed none of it.
The resident, meanwhile, had been yelling out and disrupting other residents in common areas. Paranoid, according to LPN C. Receiving a mood stabilizer, an antidepressant, and an anti-anxiety medication added in quick succession, while a wound on their heel quietly opened and grew, and their family waited for a call that never came.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkwood Skilled Nursing and Rehabilitation Center from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 23, 2026 · Our methodology
PARKWOOD SKILLED NURSING AND REHABILITATION CENTER in MARYLAND HEIGHTS, MO was cited for violations during a health inspection on November 6, 2025.
Inspectors cited Parkwood Skilled Nursing and Rehabilitation Center on November 6, 2025, following a complaint investigation.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.