ELLSWORTH, MN - Federal inspectors documented significant deficiencies in quality oversight, staff training, and infection control practices at Parkview Manor Nursing Home during a comprehensive survey conducted in June 2024, revealing systematic gaps in the facility's ability to monitor and improve care quality for its 28 residents.
Missing Facility Assessment Raises Questions About Care Planning
During the inspection, administrators at Parkview Manor acknowledged they could not locate the facility's most recent comprehensive assessment—a critical document required by federal regulations to evaluate the facility's resources and capabilities. According to inspection records, when surveyors requested the facility assessment on June 24, the administrator reported having discussed the matter with the director of nursing that same morning, revealing uncertainty about when the document had last been updated.
The administrator stated he had completed a new facility assessment approximately 30 minutes before the interview, after being unable to find the previous version. This newly created assessment identified that staff education and competencies were necessary to support resident care needs, including various certifications. The document listed required training areas including communication, resident rights, abuse prevention, neglect and exploitation awareness, culture change, and infection control procedures.
The facility assessment serves as a foundational planning document that nursing homes must maintain to demonstrate they have adequately evaluated their ability to meet residents' needs. It requires facilities to systematically review their resources, including staffing levels, equipment, and physical environment, to ensure they can provide appropriate care. When this assessment is missing or outdated, facilities lack a current roadmap for identifying gaps in their capabilities and planning necessary improvements.
Staff Training and Competency Program Deficiencies Documented
Inspectors identified substantial gaps in the facility's staff training and competency validation programs. A nursing assistant interviewed on June 25 reported that while staff completed online training modules, there was no practical skills review or competency assessment where supervisors observed their performance.
The director of nursing confirmed during a June 26 interview that department heads had not been completing annual employee evaluations, though she noted the previous administrator had completed evaluations for all department heads. She acknowledged this was an area requiring improvement. More significantly, she revealed she had not conducted any skills training or competencies with nursing staff, with the sole exception of annual training provided by an external lift company on proper mechanical lift usage.
When asked about competency assessments, the director of nursing expressed that she wished she had more time to complete such activities. This statement revealed a disconnect between regulatory requirements and operational priorities at the facility.
Staff competency validation represents a critical component of quality nursing home care. Regular competency assessments ensure that nursing assistants and licensed nurses maintain proficiency in essential skills such as proper hygiene techniques, safe resident handling, medication administration, and recognition of changes in resident condition. Without systematic competency verification, facilities cannot ensure staff members are performing care tasks correctly or identify individuals who may need additional training or support.
The absence of documented competencies creates particular concern in areas such as infection control, where improper technique can lead to disease transmission between residents. Hand hygiene, proper use of personal protective equipment, and environmental cleaning procedures all require periodic verification to ensure staff maintain proper practices over time.
Quality Improvement Program Lacks Required Analysis and Goal-Setting
Federal regulations require nursing homes to maintain active Quality Assurance and Performance Improvement (QAPI) programs that systematically monitor care quality and implement targeted improvements. Inspectors found that Parkview Manor's QAPI program lacked essential components required for effective quality monitoring.
Review of QAPI committee minutes from June 14, 2024, revealed the absence of documented facility goals and data analysis. The records showed no evidence of how the facility would meet identified goals, nor any evaluation of whether previous goals had been achieved or what new processes might be needed.
During a June 25 interview, the director of nursing acknowledged these deficiencies, agreeing that the facility was not analyzing data presented to the QAPI committee, setting measurable goals, or documenting what actions would be taken when goals were not met. She confirmed there was no formal process for staff, residents, or family members to provide feedback for quality improvement purposes.
The facility's QAPI plan policy stated that the plan should provide guidance for overall quality improvement and that the administrator should ensure annual review by the QAPI committee. The policy indicated QAPI should review data from monitored areas quarterly. However, the policy contained no mention of measurable goals, data analysis procedures, or methods for identifying whether benchmarks would be achieved. It also lacked any description of how compliance would be measured or verified.
Effective QAPI programs require facilities to establish baseline measurements for quality indicators, set specific improvement targets, implement interventions designed to achieve those targets, and then measure whether improvements occurred. This cycle of plan-do-study-act should be documented and repeated continuously. When facilities simply collect data without analysis or goal-setting, they miss opportunities to identify emerging problems and implement timely corrections.
Performance Improvement Projects Absent from Quality Program
Inspectors also found that Parkview Manor had not conducted any Performance Improvement Projects (PIPs)—focused initiatives that address high-risk or problem-prone areas through systematic data collection, analysis, and intervention. The director of nursing confirmed on June 25 that the facility had not undertaken any PIP projects, explaining that the new administrator had chosen not to participate in such projects. She acknowledged that PIPs are important for identifying high-level areas of concern to provide optimal resident care.
Performance Improvement Projects represent intensive, time-limited quality improvement efforts that facilities undertake when they identify significant quality concerns or opportunities for enhancement. These projects typically involve assembling interdisciplinary teams, conducting root cause analysis, implementing evidence-based interventions, and measuring outcomes over several months. PIPs allow facilities to focus concentrated attention on particular quality challenges and demonstrate measurable improvement.
Improper Whirlpool Tub Cleaning Procedures Create Infection Risk
Federal inspectors documented significant infection control violations related to the cleaning and disinfection of therapeutic whirlpool tubs used for resident bathing. Observations revealed that nursing assistants were not following manufacturer guidelines for proper disinfection, potentially exposing residents to infectious organisms.
On June 24, inspectors observed a nursing assistant on the north unit cleaning the whirlpool tub. The staff member sprayed the interior of the tub with Clorox Fuzion cleaner/disinfectant, scrubbed it with a long-handled brush, and waited one minute before pressing the FILL button to flush water through the jets. She then pressed and held the DISINFECT button for 30 seconds, which produced only a small amount of clear water from the jets. The nursing assistant used this water and the brush to scrub the interior of the tub, then rinsed the tub for three minutes.
When questioned, the nursing assistant was unaware how long the disinfection process should take or whether any disinfecting solution was actually coming through the jets. She wore no personal protective equipment while performing the cleaning task, despite handling chemical disinfectants.
The posted manufacturer guidelines from Cascade Aqua-Aire Tube Operation System specified a detailed 11-step process for proper whirlpool disinfection. This process included pressing and holding the DISINFECT button until cleaning solution could be seen coming from all air jets, allowing disinfectant to remain on surfaces for 10 minutes, and thorough scrubbing of all interior surfaces including the door seal and temperature probe areas.
A second observation on June 25 documented similar improper procedures. The nursing assistant pressed the FILL button, rinsed the tub for 30 seconds, then sprayed the interior with Triforce bleach solution. She stated the solution should remain on surfaces for five minutes of wet contact time. The inspection report noted the chemical smell was overpowering in the shower room. After pressing the DISINFECT button for 30 seconds, she rinsed the tub with the shower sprayer for another 30 seconds. This nursing assistant also reported the entire cleaning process took approximately 10 minutes and acknowledged being unsure whether the spray cleaner was adequate for whirlpool disinfection.
Whirlpool tubs present unique infection control challenges because water and air jets contain internal tubing and mechanisms that can harbor bacteria and other microorganisms if not properly disinfected. Unlike standard bathtubs, whirlpool systems require that disinfecting solution be circulated through the entire jet system to eliminate any biofilm or bacterial growth in the tubing. Surface spraying alone cannot reach these internal components, leaving potential reservoirs for organisms such as Pseudomonas, which can cause serious infections, particularly in elderly residents with compromised immune systems or open wounds.
Equipment Placement Prevented Proper Disinfection System Use
Investigation revealed that the facility had installed a water heater in 2016 that blocked access to the compartment designed to hold manufacturer-specified disinfectant solution for the whirlpool system. The maintenance director confirmed that the water heater installation prevented staff from accessing the solution compartment, making it impossible to refill the automated disinfection system as designed by the manufacturer.
The housekeeping supervisor acknowledged that staff should have been using the manufacturer's recommended disinfectant but explained the facility had switched to Triforce spray or Clorox Fuzion spray because the proper solution compartment could not be accessed due to the water heater placement.
During inspection, the maintenance director showed surveyors expired whirlpool disinfectant solution stored in his office with an expiration date of July 2023. He confirmed that the disinfectant solution connected to the whirlpool system had likely run dry, meaning when staff pressed the DISINFECT button, only water would flow through the jets rather than disinfecting solution.
A specialist from BETCO, the manufacturer of the Triforce solution the facility was using, confirmed during interview that the product was designed for general surface cleaning and disinfection, not specifically for whirlpool tub systems. The specialist explained that Triforce should be applied to dry surfaces with a three-minute wet contact time and that surfaces should be wiped down rather than rinsed with water. The specialist could not verify that the spray product would adequately reach all surfaces of the tub or the areas around the jets when applied by spraying.
Additional Issues Identified
The inspection documented several other compliance concerns. The facility's written whirlpool cleaning policy was undated and appeared to reference different equipment than currently in use, with instructions that did not match the manufacturer guidelines for the installed whirlpool systems. The director of nursing confirmed the facility had no formal checklist for whirlpool use and cleaning procedures and could not provide documentation showing that staff had received specific training on proper whirlpool disinfection.
The facility's training policy from 2020 indicated that initial orientation would be provided to all employees and that yearly online Healthcare Academy training would be completed. However, there was no indication that training was specific to the facility's equipment and procedures rather than generalized healthcare education.
The QAPI program deficiencies extended to the lack of established processes for measuring performance improvement or ensuring that meeting minutes were shared appropriately with residents and families. While the facility's policy stated that QAPI minutes should be kept with the administrator and made available to staff, residents, and families, there was no evidence this occurred systematically.
Federal regulations require nursing homes to maintain robust infection prevention and control programs, comprehensive quality assessment systems, and evidence of staff competency in essential care tasks. The deficiencies identified at Parkview Manor represent systematic gaps in these fundamental requirements. The facility received citations for minimal harm or potential for actual harm, indicating that while no residents were documented to have experienced adverse outcomes at the time of inspection, the identified practices created risk of harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkview Manor Nursing Home from 2024-06-26 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.