Inspection Reports for Parkside Manor
1201 HUNT AVE, COLUMBIA, MO, 65202-1367
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
71 residents
Based on a August 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Aug 7, 2025
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to maintain a clean, comfortable, and homelike environment, including concerns about carpet odor, air vent cleanliness, and potential mold in resident rooms.
Complaint Details
Complaint numbers 2575243, 2574982, 2576588, and 2578982 were investigated. The complaints were substantiated as the facility failed to maintain cleanliness and address maintenance issues, including carpet odors, mold concerns, and dirty air vents.
Findings
The facility failed to ensure carpets in shared hallways were free of unpleasant odors and stains, and air vents had excessive build-up of a black unknown substance. Multiple resident rooms showed issues such as damaged bathroom doors, missing ceiling paint, and unclean conditions. Staff did not consistently follow cleaning procedures or maintenance reporting protocols.
Deficiencies (1)
Failure to provide a clean, comfortable and homelike environment including untreated carpet odors and unclean air vents.
Report Facts
Facility census: 71.1
Number of complaints: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper C | Reported air vents covered with black substance and cleaning responsibilities | |
| Certified Medical Technician A | Certified Medical Technician | Reported resident concerns about mold and air vent conditions |
| Certified Medical Technician B | Certified Medical Technician | Reported concerns about black substance on air vents and maintenance documentation |
| Maintenance Director | Maintenance Director | Responsible for building maintenance and air vent cleaning; acknowledged issues and cleaning efforts |
| Director of Nursing | Director of Nursing | Reported resident room usage and maintenance reporting expectations |
| Housekeeping Supervisor | Housekeeping Supervisor | Oversaw floor technicians and cleaning responsibilities |
| Administrator | Administrator | Expected documentation of maintenance issues and coordinated cleaning efforts |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 4
Date: Apr 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure of facility staff to appropriately notify the resident's physician when the resident expressed suicidal ideations and failed to complete required assessments and care plans.
Complaint Details
The investigation was triggered by a complaint that facility staff failed to notify the resident's physician when the resident expressed suicidal ideations and failed to complete required assessments and care plans. The complaint was substantiated based on interviews and record reviews.
Findings
The facility failed to notify the physician when a resident expressed suicidal ideations, failed to complete the required Minimum Data Set (MDS) assessment within the required timeframe, and failed to develop a comprehensive baseline care plan for the resident. Documentation and communication deficiencies were noted, including lack of notification to the Director of Nursing and physician, and incomplete care planning.
Deficiencies (4)
Failure to notify the resident's physician when the resident expressed suicidal ideations.
Failure to complete the required Minimum Data Set (MDS) assessment within the required timeframe.
Failure to develop a comprehensive person-centered baseline care plan within 48 hours of admission.
Failure to take appropriate action and document when a resident threatened suicide, including lack of notification to Director of Nursing and physician.
Report Facts
Facility census: 77
MDS admission assessment due date: Apr 2, 2025
Inspection completion date: Apr 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Spoke with resident about suicidal ideations but did not notify DON or physician |
| Director of Nursing | DON | Expected to be notified of suicidal ideations but was not notified |
| Administrator | Facility Administrator | Expected charge nurse to notify DON and physician and ensure monitoring and documentation |
| Assistant Director of Nursing | ADON | Responsible for ensuring baseline care plan completion |
| MDS Coordinator | MDS Coordinator | Responsible for completing admission MDS assessment |
| Physician's Nurse | Physician's Nurse | Reported no record of facility contacting physician's office regarding suicidal comments or emotional distress |
Inspection Report
Census: 73
Deficiencies: 1
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with notification requirements related to resident incidents and injuries.
Findings
Facility staff failed to notify one resident's representative when the resident's toilet became unsecured and tipped, requiring a room change. Additionally, staff failed to notify physicians in a timely manner for two residents with skin injuries.
Deficiencies (1)
Failure to immediately notify the resident, the resident's doctor, and a family member of situations affecting the resident, including an unsecured toilet incident and delayed physician notification for skin injuries.
Report Facts
Census: 73
Inspection Report
Routine
Census: 66
Deficiencies: 10
Date: Dec 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, staffing, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to notify physicians and representatives timely about resident incidents, failure to follow physician orders for medication administration via feeding tubes, inadequate activity programming for residents on the Memory Care Unit, lack of communication with dialysis providers, insufficient nursing staff coverage especially on night shifts, failure to ensure nurse aides completed required training timely, lack of collaboration and documentation with hospice providers, failure to implement enhanced barrier precautions properly, and failure to implement an antibiotic stewardship program.
Deficiencies (10)
Failure to notify resident's physician and representative timely about incidents involving residents #24 and #32.
Failure to follow physician's orders regarding water flushes during medication administration for residents #12 and #38 with feeding tubes.
Failure to provide an ongoing program of daily activities designed to meet the interests of residents on the Memory Care Unit.
Failure to have a system in place for ongoing communication with the dialysis clinic for resident #20.
Failure to provide adequate nursing staff on night shift as per facility assessment.
Failure to provide services of a Registered Nurse for at least eight consecutive hours per day, seven days a week.
Failure to ensure nurse aides completed nurse aide training program within four months of employment.
Failure to document collaboration of care with hospice providers and maintain communication documentation for residents #2 and #44 receiving hospice services.
Failure to implement Enhanced Barrier Precautions (EBP) policy including failure to place EBP signs and PPE in proximity, and failure to use appropriate PPE for residents requiring EBP.
Failure to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use.
Report Facts
Facility census: 66
Deficiency count: 10
Staffing requirement: 2
Staffing requirement: 5
Nurse aide certification timeframe: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN G | Licensed Practical Nurse | Named in medication administration and infection control findings |
| LPN A | Licensed Practical Nurse | Named in notification failure findings |
| CNA J | Certified Nursing Assistant | Named in activity programming findings |
| AD | Activities Director | Named in activity programming findings |
| DON | Director of Nursing | Named in multiple findings including staffing, infection control, and antibiotic stewardship |
| ADON | Assistant Director of Nursing | Named in staffing and nurse aide training findings |
| IP | Infection Preventionist | Named in infection control and antibiotic stewardship findings |
| Administrator | Facility Administrator | Named in multiple findings including staffing, infection control, and antibiotic stewardship |
| LPN N | Licensed Practical Nurse | Named in dialysis communication findings |
| NA C | Nurse Aide | Named in nurse aide training findings |
Inspection Report
Routine
Census: 67
Deficiencies: 1
Date: Sep 16, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on the proper sanitization and use of a multiple-use glucometer among residents.
Findings
The facility staff failed to provide a protective barrier for the glucometer supplies and did not appropriately sanitize the glucometer between use for four sampled residents. Observations and interviews confirmed lapses in sanitization practices, posing a potential risk for cross-contamination.
Deficiencies (1)
Failure to provide a barrier for the glucometer supplies and failure to appropriately sanitize a multiple-use glucometer between use for four residents.
Report Facts
Facility census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Observed failing to sanitize glucometer properly and not using a protective barrier |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding sanitization procedures and lack of knowledge of manufacturer's instructions |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about staff directions to sanitize glucometer and use protective barriers |
| Administrator | Administrator | Interviewed about staff directions to sanitize glucometer and use protective barriers |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Apr 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure of facility staff to document medication administration and reasons for missed medications for two residents.
Complaint Details
The complaint investigation found that staff did not document administration of medications or reasons for missed doses for Resident #1 and Resident #2. Interviews with the Director of Nursing, Assistant Director of Nursing, and Licensed Practical Nurse confirmed that documentation expectations were not being met and reasons for missed medications were not consistently recorded.
Findings
The facility staff failed to meet professional standards by not documenting administration of medications or reasons for missed doses for two residents. Interviews with nursing staff confirmed expectations for documentation were not consistently met.
Deficiencies (1)
Facility staff failed to document medication administration and reasons for missed medications for two residents.
Report Facts
Facility census: 68
Medication doses not documented: 10
Medication doses not documented: 10
Medication doses not documented: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication documentation expectations and deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding medication documentation expectations and deficiencies |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding medication documentation practices and deficiencies |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Date: Jan 25, 2024
Visit Reason
The inspection was conducted due to a complaint regarding improper use of a mechanical lift transfer that resulted in injury to a resident's arm.
Complaint Details
The complaint investigation found that staff failed to use two-person assistance during a mechanical lift as required, causing injury to Resident #1. The injury was substantiated by medical records including X-ray showing a fracture. Interviews with staff and administration confirmed the policy and expectation for two-person lifts.
Findings
Facility staff failed to provide a proper mechanical lift transfer for one resident, resulting in an acute left proximal humeral fracture. Staff did not follow the facility policy requiring two staff members to assist with mechanical lifts, leading to actual harm to the resident.
Deficiencies (1)
Failure to provide a proper mechanical lift transfer resulting in injury to a resident's arm.
Report Facts
Facility census: 72
Date of resident assessment: Dec 13, 2023
Date of resident care plan: Jun 22, 2023
Date of injury nurse note: Jan 20, 2024
Date of X-ray report: Jan 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant A | CNA | Performed the mechanical lift alone and described the incident |
| Certified Nursing Assistant B | CNA | Stated staff are directed to always have two staff with a hoyer lift |
| Licensed Practical Nurse C | LPN | Confirmed it is not standard to perform hoyer lifts with one person |
| Director of Nursing | DON | Confirmed staff are trained to use two people for hoyer lifts |
| Assistant Director of Nursing | ADON | Expressed lack of knowledge why CNA A performed lift alone |
| Administrator | Administrator | Stated staff are expected to use two staff members for mechanical lifts |
Inspection Report
Routine
Census: 74
Deficiencies: 17
Date: Aug 23, 2023
Visit Reason
Routine inspection of Parkside Manor nursing home to assess compliance with regulatory requirements including resident rights, care planning, medication administration, infection control, environment, and activities.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding and care, inadequate response to resident council grievances, failure to post resident rights accessibly, breaches in resident privacy, unsanitary environment conditions, incomplete care plans, medication errors, unsafe smoking supervision, improper medication storage, inadequate infection control practices, and failure to maintain immunization records and provide activities to meet resident needs.
Deficiencies (17)
Facility staff failed to maintain resident dignity by not sitting while feeding residents and not providing privacy during care.
Facility staff failed to provide resident council with written responses to grievances.
Facility staff failed to post Resident Rights in an accessible area to residents and visitors.
Facility staff failed to keep residents' personal and medical records private and confidential by leaving medication administration records open and unattended.
Facility staff failed to maintain a clean, comfortable, and homelike environment including persistent urine odors, damaged room fixtures, and use of Styrofoam and plastic dinnerware for meals.
Facility staff failed to notify residents or representatives in writing of bed hold policies at time of hospital transfer for multiple residents.
Facility staff failed to ensure appropriate PASARR screening for mental disorders or intellectual disabilities for several residents.
Facility staff failed to develop comprehensive person-centered care plans addressing cognitive status, code status, falls, pain, and ADLs for multiple residents.
Facility staff failed to review and revise care plans timely for nutrition, pressure ulcer risk, falls, and ADL needs for multiple residents.
Facility staff failed to meet professional standards of practice including post-dialysis assessments, medication order clarifications, application of ace wraps, completion of skin assessments, weights, blood work, neurological assessments, and narcotic counts.
Facility staff failed to provide appropriate care and assistance with activities of daily living including hygiene, dressing, nail care, and clothing changes for multiple residents.
Facility staff failed to provide an ongoing program of activities designed to meet residents' interests and needs, especially on the secured unit.
Facility staff failed to ensure unsafe smokers were supervised, failed to properly store razors and hazardous chemicals, failed to maintain medication safety by leaving carts unlocked and unattended, and failed to properly propel residents in wheelchairs and perform mechanical lifts.
Facility staff failed to ensure medication error rate was less than 5%, with six errors observed out of 43 opportunities affecting four residents.
Facility staff failed to store and label medications in a safe and effective manner in medication storage rooms and carts, including presence of food and beverages in medication rooms, undated and opened medications, and unclean medication carts.
Facility staff failed to maintain an infection prevention and control program including failure to perform hand hygiene during catheter care, wound care, and medication administration, improper cleaning and storage of CPAP nasal pillows, and failure to complete and document two-step Mantoux TB tests and annual TB screenings for multiple residents.
Facility staff failed to maintain and follow policies and procedures for resident immunizations against pneumococcal disease and failed to assess and vaccinate multiple residents.
Report Facts
Facility census: 74
Medication error rate: 13.95
Medication errors: 6
Medication administration opportunities: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA G | Certified Nurse Aide | Named in resident dignity and privacy findings |
| CNA L | Certified Nurse Aide | Named in resident dignity and privacy findings |
| Administrator | Administrator | Named in resident dignity and privacy findings and interview |
| Director of Nursing | Director of Nursing (DON) | Named in resident dignity, privacy, care planning, medication, infection control, and activities findings and interviews |
| CNA N | Certified Nurse Aide | Named in resident dignity and privacy findings and smoking supervision |
| LPN A | Licensed Practical Nurse | Named in resident dignity, privacy, medication, infection control, and smoking supervision findings and interviews |
| CMT M | Certified Medication Technician | Named in resident dignity and privacy findings |
| Social Service Director | Social Service Director (SSD) | Named in resident council grievance and activities findings and interview |
| Social Service Designee | Social Service Designee (SSD) | Named in bed hold and PASARR findings and interview |
| CMT B | Certified Medication Technician | Named in resident privacy and medication administration findings and interview |
| CMT D | Certified Medication Technician | Named in resident privacy and medication administration findings and interview |
| CNA I | Certified Nurse Assistant | Named in hazardous materials storage and wheelchair propulsion findings and interview |
| CNA L | Certified Nurse Assistant | Named in hazardous materials storage and wheelchair propulsion findings and interview |
| CNA O | Certified Nurse Assistant | Named in wheelchair propulsion findings and interview |
| LPN F | Licensed Practical Nurse | Named in medication administration findings and interview |
| CMT P | Certified Medication Technician | Named in medication administration and medication cart security findings and interview |
| CMT R | Certified Medication Technician | Named in medication administration and medication cart security findings and interview |
| CNA W | Certified Nurse Aide | Named in infection control findings and interview |
| NA X | Nurse Aide | Named in infection control findings |
| LPN A | Licensed Practical Nurse | Named in infection control findings and interview |
| RN C | Registered Nurse | Named in infection control and medication administration findings and interview |
| LPN A | Licensed Practical Nurse | Named in infection control and medication administration findings and interview |
| LPN A | Licensed Practical Nurse | Named in infection control and medication administration findings and interview |
| LPN F | Licensed Practical Nurse | Named in medication administration findings and interview |
| CMT B | Certified Medication Technician | Named in medication administration findings and interview |
| CMT D | Certified Medication Technician | Named in medication administration findings and interview |
| CMT R | Certified Medication Technician | Named in medication administration findings and interview |
| LPN A | Licensed Practical Nurse | Named in medication administration findings and interview |
| CMT P | Certified Medication Technician | Named in medication administration findings and interview |
| CMT E | Certified Medication Technician | Named in medication administration findings and interview |
| LPN F | Licensed Practical Nurse | Named in medication administration findings and interview |
| LPN A | Licensed Practical Nurse | Named in medication administration findings and interview |
| CNA N | Certified Nurse Assistant | Named in smoking supervision findings and interview |
| LPN A | Licensed Practical Nurse | Named in smoking supervision findings and interview |
| CNA H | Certified Nurse Assistant | Named in smoking supervision findings and interview |
| ADON | Assistant Director of Nursing | Named in smoking supervision and mechanical lift findings and interview |
| CNA O | Certified Nurse Assistant | Named in mechanical lift findings and interview |
Inspection Report
Routine
Census: 64
Deficiencies: 11
Date: Jul 28, 2022
Visit Reason
Routine inspection of Parkside Manor nursing home to assess compliance with regulatory requirements including resident care, environment, activities, and infection control.
Findings
The inspection found multiple deficiencies including failure to maintain a clean and homelike environment, inadequate staff screening, incomplete and inaccurate resident assessments and care plans, insufficient supervision of residents while smoking, inadequate activities programming especially on the dementia unit, improper food storage and preparation, failure to properly sanitize dishes, and inconsistent use of facemasks by staff. Several residents were observed with unmet care needs such as poor hygiene and unsafe smoking practices.
Deficiencies (11)
Failure to maintain a clean, comfortable, and homelike environment including pest control and cleanliness of resident linens.
Failure to complete required Nurse Aide Registry checks on five out of ten sampled employees prior to hire.
Failure to complete Significant Change of Status Assessments and inaccurate coding of resident conditions on MDS.
Failure to develop and update comprehensive person-centered care plans for residents, including supervision while smoking.
Failure to provide consistent documentation and physician orders for residents' code status (POLST).
Failure to provide appropriate care and assistance with activities of daily living including hygiene, nail care, and clothing changes.
Failure to provide an ongoing program of activities designed to meet residents' interests on the dementia unit.
Failure to ensure the activities program was directed by a qualified professional.
Failure to store food properly to prevent contamination and out-dated use; failure to sanitize dishes properly and allow air drying before storage.
Failure to wear facemasks appropriately throughout the facility to prevent spread of COVID-19 and failure to provide perineal care in a manner to prevent infection.
Failure to ensure supervision of residents while smoking, failure to propel wheelchair residents properly, and failure to implement interventions to prevent resident entrapment.
Report Facts
Facility census: 64
Deficiencies cited: 11
Opened food items undated: 26
Sanitizer concentration check missing days: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Mentioned in relation to facemask use, MDS accuracy, and resident care |
| CMT H | Certified Medication Technician | Mentioned in relation to facemask use, resident care, smoking supervision, and MDS accuracy |
| CNA L | Certified Nurse Aide | Mentioned in relation to facemask use, smoking supervision, and resident care |
| CNA K | Certified Nurse Aide | Mentioned in relation to wheelchair propulsion and resident care |
| DA P | Dietary Aide | Mentioned in relation to dishwashing and food service |
| DM | Dietary Manager | Mentioned in relation to food service and menu compliance |
| Administrator | Facility Administrator | Mentioned in relation to facility policies, food service, and activities |
| DON | Director of Nursing | Mentioned in relation to resident care, MDS, smoking supervision, and infection control |
| RN G | Registered Nurse | Mentioned in relation to MDS accuracy, smoking supervision, and activities |
| CNA M | Certified Nurse Aide | Mentioned in relation to perineal care and infection control |
| AD | Activity Director | Mentioned in relation to activities program and qualifications |
| Maintenance Director | Maintenance Director | Mentioned in relation to pest control and facility repairs |
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