Prairie Village Healthcare Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Jacksonville, Illinois.
- Location
- 1024 West Walnut, Jacksonville, Illinois 62650
- CMS Provider Number
- 145294
- Inspections on file
- 16
- Latest survey
- October 24, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Prairie Village Healthcare Ctr during CMS and state inspections, most recent first.
A resident with an open lesion on the right foot was found by a podiatrist to have insects between the toes, but the nurse who cleaned the area did not document the presence or removal of insects in the medical record. Other staff were unaware or did not observe insects, and the facility's documentation policy requiring all changes in condition to be recorded was not followed, resulting in an incomplete record.
A resident's medical record was incomplete due to missing documentation from a podiatrist's assessment. The LPN confirmed the podiatrist had seen the resident, but no progress notes were found in the EMR. The administrator stated that the podiatrist does not provide his notes to the facility, while the podiatrist believed his office was sending them as required by facility policy.
Two residents with complex medical conditions did not receive pulse oximetry monitoring as ordered by their physicians. Documentation review showed that required twice-daily oxygen saturation checks were frequently missed or not recorded, and the process for recording and entering these results into the EMR was inconsistent. Staff interviews confirmed that CNAs collected the data and handed it to a nurse for EMR entry, but this did not ensure compliance with orders or facility policy.
A resident with significant risk factors for pressure ulcers, including diabetes, end stage renal disease, and impaired mobility, developed a new stage 2 pressure ulcer in the upper intergluteal cleft that was not identified or documented by staff until found during a skin check with LPNs and a surveyor. Despite care plan interventions and facility policy requiring regular skin assessments and prompt reporting, the wound was not noted in prior documentation.
A resident with diabetes, renal dialysis dependence, and polyneuropathy developed a left heel pressure ulcer that was not promptly identified or treated according to physician orders. The wound was discovered by nursing staff, and documentation showed missed dressing changes and inconsistent risk assessment, despite the resident's impaired mobility and history of pressure ulcers.
The facility did not have a full-time DON for several weeks and failed to provide RN coverage for at least 8 hours a day on multiple days, contrary to its own staffing policy and regulatory requirements. This affected all 46 residents in the facility.
Surveyors found that expired insulin pens, vials, and a multi-use tuberculin vial were not properly dated or disposed of as required. An LPN and an RN confirmed that opened medications were not consistently labeled with open dates, and expired medications remained in use, affecting all residents in the facility.
Surveyors found that bulk food items such as breadcrumbs, flour, sugar, and oats were stored in open bags inside plastic bins without lids, covered only by trash bags. The Dietary Manager confirmed that this method could allow pests to access the food, which is not in accordance with facility policy requiring tight-fitting lids for food storage.
Staff failed to provide adequate privacy and dignity during care, including feeding and wound care, for multiple residents with cognitive impairments and complex medical needs. CNAs assisted residents with meals while standing over them, and LPNs performed personal care and treatments without closing window blinds or privacy curtains, exposing residents to potential view from outside or from roommates. Staff interviews confirmed that proper privacy protocols were not consistently followed.
Nursing staff failed to consistently follow infection control protocols, including proper use of PPE, hand hygiene, and disinfection of reusable medical equipment during wound care and medication administration for several residents on enhanced barrier precautions. Staff entered rooms without required gowns, did not always perform hand hygiene before donning gloves or between glove changes, and placed supplies on unclean surfaces without barriers, contrary to facility policy.
The facility failed to provide 8 consecutive hours of RN coverage, affecting all 48 residents. The schedule did not document an RN working for 8 consecutive hours on multiple dates. The previous DON ended her employment, and the Interim DON quit, resulting in the loss of RN coverage.
An LPN failed to properly disinfect a multi-use blood glucose machine, affecting seven residents. The machine was not fully wiped down as per the instructions on the Microdot Bleach Wipe container, which required a 30-second contact time to kill bacteria and viruses.
The facility failed to follow physician-ordered treatment for a resident's pressure sore on the left heel. An LPN observed that the dressing used was not as per the physician's orders, which required specific moisturizers and dressings. The resident's care plan and facility policy were not adhered to in this instance.
Failure to Document and Address Insects Found on Resident's Foot
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's foot was free of insects. The resident, who was alert and had a care plan for an open lesion between the 4th and 5th toes of the right foot, was observed by a podiatrist to have a 'family of insects' in the webspace of the affected toes. The podiatrist reported this finding to a nurse, who then cleansed the area but did not document the presence or removal of insects in the resident's medical record. The care plan for the resident included regular wound care, skin assessments, and monitoring for signs of infection, but there was no documentation of insects or maggots in the resident's records prior to or after the podiatrist's observation. Multiple staff interviews revealed inconsistent awareness and documentation regarding the presence of insects. The nurse who was informed by the podiatrist admitted to assessing and cleaning the area but did not record the incident, citing being busy and forgetting to document. Other staff, including the acting wound nurse and the DON, stated that they did not observe insects or maggots and were not informed by other staff of such findings. The wound nurse also noted a lack of access to the podiatrist's notes, which contributed to incomplete information in the resident's record. The facility's documentation policy requires that all services provided, changes in condition, and unusual findings be recorded in the resident's medical record, including the date, time, and name of the person providing care. Despite this policy, the presence of insects was not documented at the time of the incident, and the only mention was an addendum added by the podiatrist several days later. This failure to document a significant change in the resident's condition resulted in an incomplete and inaccurate medical record.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident. The resident's face sheet did not document any diagnosis of wounds or skin issues, including maggots, and her Minimum Data Set indicated she was alert. The facility's LPN reported that the facility podiatrist assessed the resident, but there was no documentation of the podiatrist's progress notes in the resident's electronic medical record. The administrator confirmed that the podiatrist does not share or send his progress notes to the facility and never has. The podiatrist stated that his office typically sends progress notes to the facility within a few days after assessments and was unaware that the facility was not receiving or uploading these notes. The facility's policy requires all observations and services performed to be documented in the resident's clinical record.
Failure to Follow Physician Orders for Pulse Oximetry Monitoring
Penalty
Summary
The facility failed to follow physician orders for twice-daily pulse oximetry checks for two residents with significant medical conditions. One resident, with diagnoses including polyneuropathy, diabetes, end stage renal disease, dependence on dialysis, right below the knee amputation, and obstructive sleep apnea, had a physician order for oxygen saturation monitoring twice daily. However, review of the electronic medical record showed that oxygen saturations were not performed twice daily as ordered on 17 occasions within the first 25 days of June, and there were also days with no documentation at all. The resident's care plan did not include oxygen saturation monitoring as a problem or intervention. Another resident, with a history of fibromyalgia, diabetes, chronic obstructive pulmonary disease, asthma, pulmonary hypertension, and congestive heart failure, also had a physician order to monitor oxygen saturations every shift and as needed. Review of documentation for the first 25 days of June revealed that only one day had twice-daily readings, and on 12 days there were no oxygen saturation levels recorded. Interviews with CNAs and an LPN confirmed that CNAs obtain pulse oximetry readings with vital signs, record them on paper, and provide them to the nurse for entry into the EMR, but the process did not ensure compliance with the physician's orders. The facility's policy required documentation of the date and time of the procedure, and reasons for refusal if applicable, but this was not consistently followed.
Failure to Timely Identify and Document New Pressure Ulcer
Penalty
Summary
The facility failed to identify a stage 2 pressure ulcer in a timely manner for a resident with multiple risk factors, including polyneuropathy, diabetes, end stage renal disease, and impaired mobility. During a skin check, a new pressure wound was discovered in the upper intergluteal cleft by two LPNs and the surveyor, with both nurses acknowledging they were previously unaware of the wound. The resident's care plan indicated a high risk for pressure ulcers and included interventions such as regular skin inspections during showers, use of pressure-reducing devices, and prompt reporting of skin breakdown. However, documentation on shower sheets and treatment administration records did not reflect the presence of the new wound prior to its discovery. The resident required supervision and assistance with activities of daily living and was known to have other unstageable pressure ulcers. Despite these risk factors and the facility's policy for routine skin assessments and immediate reporting of developing pressure injuries, the new stage 2 pressure ulcer was not identified or documented until the surveyor's observation. The lack of timely identification and documentation represents a failure to follow established protocols for pressure ulcer prevention and monitoring.
Failure to Prevent and Timely Treat Pressure Ulcer
Penalty
Summary
A facility failed to identify and prevent the development of a pressure ulcer for one resident, resulting in the formation of a left heel pressure ulcer. The resident, who has a history of diabetes, dependence on renal dialysis, and polyneuropathy, was found to have an unstageable pressure ulcer with necrotic tissue and moderate drainage. The resident reported not being aware of the ulcer until it was discovered by a nurse, and expressed concern due to a previous amputation related to a non-healing pressure ulcer. Documentation revealed that the dressing was not changed daily as ordered, with a missed treatment noted on the treatment administration record. The wound was observed to have a dressing dated two days prior, and the wound nurse practitioner performed wound care during the surveyor's observation. The resident's care plan identified a risk for pressure ulcers due to impaired mobility, but the Braden Scale assessment did not indicate risk, and the Minimum Data Set did not document a pressure ulcer. Facility policy requires routine skin assessments and immediate reporting of any developing pressure injuries, but the pressure ulcer was not identified until it had already developed. The facility's failure to consistently assess, document, and provide timely wound care contributed to the development and progression of the pressure ulcer.
Failure to Provide Full-Time DON and Required RN Coverage
Penalty
Summary
The facility failed to provide a full-time Director of Nursing (DON) and did not ensure that a Registered Nurse (RN) was on duty for at least 8 hours a day, seven days a week, as required. According to the Administrator, the facility had been without a DON for six weeks, and although efforts were made to hire one, there was no DON present during the survey period. The staffing schedule revealed that on 8 out of 17 days, the facility did not have RN coverage for the required 8 hours, and on several days during the survey, no RN was observed on duty. The facility's own staffing policy states that an RN will be scheduled for at least one continuous 8-hour shift each day and that all department directors, including the DON, are to be employed for a forty-hour week. Despite these policies, the facility did not meet these staffing requirements, potentially affecting all 46 residents in the facility at the time of the survey.
Failure to Dispose of Expired Medications and Date Multi-Use Vials
Penalty
Summary
Surveyors identified that the facility failed to properly dispose of expired medications and did not consistently date multi-use medication vials and insulin pens. During a review of the medication cart and medication room, it was observed that a Glargine insulin pen and a Glargine insulin vial had been opened and dated well beyond their recommended usage periods, and a stock vial of Lispro was also found with an outdated open date. Additionally, an open vial of Aplisol (tuberculin) was found in the medication refrigerator without an open date, contrary to facility policy and manufacturer recommendations. Interviews with facility staff confirmed that all insulin pens, vials, and multi-use injectable medications are required to be dated when opened, and that only one Aplisol vial is kept in the facility at a time. Facility policy and manufacturer guidelines specify that opened vials should be dated and discarded after a set period, typically 28 to 30 days. The failure to follow these procedures was observed to have the potential to affect all 46 residents in the facility.
Improper Food Storage Increases Risk of Contamination
Penalty
Summary
The facility failed to store food in a manner that prevents contamination by pests. During a tour of the dry storage area with the Dietary Manager, surveyors observed large plastic storage bins containing open 25-pound bags of breadcrumbs, flour, sugar, and instant oats. These bins did not have lids and instead had trash bags draped over them. The Dietary Manager acknowledged that pests could crawl under the trash bags and access the food. Facility policy requires that plastic containers with tight-fitting lids be used for storing such items and that open products be tightly covered to protect against contamination, including from insects and rodents. At the time of the survey, there were 46 residents living in the facility.
Failure to Ensure Resident Privacy and Dignity During Care
Penalty
Summary
The facility failed to provide privacy and promote dignity for six residents during care activities, as observed by surveyors. Certified Nurse Assistants (CNAs) assisted residents with eating while standing over them, rather than sitting at eye level, which did not respect the residents' dignity. Residents involved had significant cognitive impairments and required varying levels of assistance with eating. Staff interviews confirmed awareness that proper feeding assistance should involve sitting with residents, but this was not consistently practiced. Additionally, Licensed Practical Nurses (LPNs) performed wound care and enteral feeding without ensuring adequate privacy. In several instances, window blinds were left open during personal care, exposing residents to potential view from outside or from roommates. Privacy curtains were not always used, and in one case, a resident's buttocks were exposed to an open window while being changed. The residents affected had diagnoses such as Parkinson's Disease, Schizophrenia, Alzheimer's Disease, and severe cognitive impairment. Staff acknowledged after the fact that privacy measures, such as closing blinds and curtains, should have been implemented.
Infection Control Lapses in PPE Use, Hand Hygiene, and Equipment Disinfection
Penalty
Summary
Multiple instances of non-compliance with infection prevention and control protocols were observed among nursing staff during resident care activities. In several cases, staff failed to don required personal protective equipment (PPE), such as gowns and gloves, when providing wound care to residents on Enhanced Barrier Precautions due to open wounds. For example, a nurse entered a resident's room to perform heel wound treatment without wearing a gown, despite signage and physician orders indicating the need for enhanced precautions. In another instance, a wound nurse practitioner provided pressure ulcer care without wearing a gown and handled supplies and equipment in a manner inconsistent with infection control policies. Hand hygiene lapses were also documented, including staff donning gloves without prior hand cleansing, changing gloves without performing hand hygiene in between, and handling clean and soiled items with the same gloves. During medication administration, a nurse was observed dumping pills into her gloved hand before placing them in medication cups, which is not in line with proper hand hygiene and medication handling procedures. Additionally, reusable medical equipment such as scissors was not consistently disinfected between uses, and clean barriers were not always used when placing supplies on resident surfaces during wound care. Facility policies require the use of specific disinfectants for non-critical items, preparation of clean work areas with protective barriers, and strict adherence to hand hygiene before and after resident contact, glove changes, and handling of clean or soiled dressings. The observed practices deviated from these policies, as staff failed to consistently follow established protocols for PPE use, hand hygiene, and equipment disinfection during high-contact resident care activities, particularly for residents with wounds or on enhanced barrier precautions.
Failure to Provide 8 Consecutive Hours of RN Coverage
Penalty
Summary
The facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage, which has the potential to affect all 48 residents residing in the facility. The schedule dated 3/4/24 - 3/17/24 did not document an RN working for 8 consecutive hours on multiple dates, specifically 3/5/24, 3/6/24, 3/7/24, 3/8/24, 3/10/24, 3/11/24, 3/13/24, 3/16/24, and 3/17/24. The Administrator stated that the previous Director of Nurses (DON) ended her employment on 1/18/24, and the Interim DON worked from 1/18/24 until 3/4/24 before quitting, which resulted in the loss of RN coverage. The Long-Term Care Facility Application for Medicare and Medicaid, dated 4/8/24, documents that 48 residents reside in the facility.
Improper Disinfection of Blood Glucose Machine
Penalty
Summary
The facility failed to properly disinfect a multi-use blood glucose machine for seven residents. An LPN obtained a blood glucose level for a resident and then placed the machine on a clean tissue on her medication cart. She used a Microdot Bleach wipe to gently wrap the machine and set a timer for three minutes but did not rub the entire machine with the wipe. The facility's documentation indicated that the machine was used by multiple residents. The Microdot Bleach Wipe container instructions required a 30-second contact time to kill bacteria and viruses, which was not followed correctly.
Failure to Follow Physician-Ordered Treatment for Pressure Ulcer
Penalty
Summary
The facility failed to provide the physician-ordered treatment for a pressure sore on a resident's left heel. During a dressing change, an LPN/wound nurse observed that the resident's left heel had a boggy and black circular area and an open area on the left metatarsal. The dressing used on the left heel was not in accordance with the physician's orders, which specified the use of a skin moisturizer, cushion with an abdominal pad or foam heel cup, and securing with kerlix or gauze wrap. The resident's care plan also documented the need for treatments per physician orders. The facility's policy required physician authorization for wound treatments, including dressings and topical agents, which was not followed in this instance.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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