The 30-bed facility failed to notify the resident's representative about significant changes in condition, federal inspectors found during a December 23 complaint investigation.
Resident 31 arrived at the facility on November 11 after reporting a 45-pound intentional weight loss over three months while hospitalized. Hospital records show the resident weighed 159 pounds on admission day.
The resident carried multiple serious diagnoses: acute respiratory failure with hypoxia, severe protein calorie malnutrition, Parkinson's disease, a right lung mass, pneumonia, and a chronic buttock ulcer. A physician ordered weekly weights for four weeks, then monthly monitoring.
But the facility never documented an admission weight. The first recorded weight came eight days later.
On November 19, the resident weighed 148 pounds. Five days later, the weight had dropped to 145 pounds.
Nobody weighed the resident again before discharge on December 4.
The facility's dietician noticed the problem on November 24, documenting that despite the resident eating 75 to 100 percent of meals, the weight loss continued. The dietician recommended health shakes and frozen nutritional supplements to boost protein and calories.
That same day, physicians ordered twice-daily nutritional shakes and 30 milliliters of daily protein supplement. They also upgraded the resident's diet from mechanical soft consistency to regular texture with nectar-thickened fluids.
The dietician's recommendation for frozen nutritional supplements never became a physician order.
More significantly, nursing notes contain no evidence that anyone called the resident's representative about the 14-pound weight loss or the new medical interventions.
Regional Clinical Registered Nurse 120 confirmed to inspectors on December 23 that no documentation existed showing family notification about either the weight decline or the dietary changes.
The resident had severe cognitive impairment according to the admission assessment, making family communication especially critical for care decisions.
Federal regulations require nursing homes to immediately notify residents, their doctors, and family members of situations affecting the resident's condition. The facility's own policy, revised in February 2021, specifically states that representatives will be notified of changes in physical condition and the need to alter medical treatment.
The violation affected one of three residents reviewed for condition changes during the inspection.
Parkview Care Center discharged the resident after a 23-day stay. The inspection report provides no information about the resident's condition at discharge or whether the weight loss ever stabilized.
The facility must submit a plan of correction to continue participating in Medicare and Medicaid programs. The deficiency represents minimal harm or potential for actual harm to residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkview Care Center from 2025-12-23 including all violations, facility responses, and corrective action plans.