Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Prairie Village Healthcare Ctr during CMS and state inspections, most recent first.
A resident with dementia and a history of prostate cancer experienced a delay of several days in obtaining an ordered urine culture, during which time his condition worsened. The Administrator inserted a Foley catheter instead of the ordered straight catheter to obtain a specimen, left it in place when no urine was obtained, and the resident was later found in the hospital to have a mispositioned Foley with a partially inflated balloon in the urethra causing obstruction, hematuria, infection, urosepsis, and septic shock, ultimately resulting in death from sepsis and UTI. Surveyors also observed multiple CNAs and a nurse providing catheter and peri‑care to several residents without following EBP/PPE requirements, using improper glove and hand hygiene practices, failing to rinse and dry after cleansing, omitting ordered barrier creams and catheter securement devices, and not performing complete incontinence care to the peri‑area, buttocks, and inner thighs, contrary to facility policies for catheterization, catheter care, perineal care, and suprapubic catheter care.
Staff failed to follow infection control requirements for multiple residents on Contact Isolation or Enhanced Barrier Precautions (EBP). In several cases, an LPN and CNAs entered rooms clearly marked with isolation or EBP signage and available PPE to perform wound care, g-tube care, toileting, peri-care, and catheter care while wearing only gloves and no gowns or other required PPE. One LPN reconnected a g-tube and handled the device without full PPE and left the room without performing hand hygiene. A CNA provided peri-care and catheter care using a single pair of soiled gloves for both dirty and clean tasks and for handling linens, without changing gloves or performing hand hygiene. Staff interviews revealed inconsistent understanding of EBP, despite facility policies requiring gown and glove use for high-contact care, proper glove changes, and hand hygiene before and after resident contact and PPE use.
A resident with severe cognitive impairment, incontinence, and existing pressure injuries did not consistently receive ordered pressure ulcer treatments, and staff failed to follow updated wound care orders and infection control practices. Physician orders for a hydrocolloid dressing to the buttock were not documented as completed according to the prescribed schedule, and after hospitalization, new orders for Triad paste and moisture barrier were in place. During observed wound care, an LPN and a CNA entered a contact isolation room without appropriate PPE, removed an undated hydrocolloid dressing that was no longer ordered, minimally cleansed the wound, applied Triad paste, and left the resident without a dressing or brief, while the LPN later acknowledged that the hydrocolloid dressing should not have been used. The DON and IP stated that nurses are expected to discontinue outdated orders and follow current TAR entries for wound care.
A resident with COPD, chronic respiratory failure with hypoxia, dependence on supplemental O2, and obstructive sleep apnea had physician orders for CPAP/BiPAP at nap time and night to maintain SpO2 > 92%, and for 3 L O2 via NC if CPAP was refused or unavailable. Progress notes show the resident complained of SOB at bedtime, required a nebulizer treatment, and was placed on continuous O2 via NC after staff noted the CPAP mask was broken and needed replacement. The following day, documentation again noted the broken mask and indicated a new mask would arrive the next day, while the resident remained on O2 via NC. The DON stated that broken masks are reported to the medical supply provider and that a physician should be notified if a resident with respiratory failure has SOB and no mask available, and the supplier confirmed a replacement mask was sent the day after the problem was documented.
Two residents did not receive medications as ordered, including an antibiotic for a UTI and an anticonvulsant. One resident with a suprapubic catheter and UTI returned from the hospital with an order for Cefdinir every 12 hours but received only one dose over several days, despite the drug being available in the dispensing machine and the order remaining active. The same resident also received an incorrect dose of folic acid when stock 400 mcg was given instead of the ordered 1 mg. Another resident with CKD on dialysis and a seizure history had Levetiracetam ordered on specific days but missed a scheduled dose when an LPN stated the facility was out of the medication, even though Keppra was available in the dispensing machine. These events occurred despite a facility policy requiring administration of medications as prescribed, use of backup supplies, and adherence to the five rights of medication administration.
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.
Improper Catheter Management and Incomplete Incontinence Care Leading to UTI and Sepsis
Penalty
Summary
The deficiency involves failures in timely urine specimen collection, proper catheter insertion, and adherence to infection control and perineal care practices for multiple residents. One resident with metabolic encephalopathy, dementia, and a history of prostate cancer post‑prostatectomy had an MDS indicating dependence on staff for toileting hygiene and documentation that he was always continent of urine, yet his care plan listed bladder incontinence and interventions to report signs of UTI. Progress notes documented agitation and aggression and an order for urine culture and sensitivity, but facility staff did not obtain a urine sample for four days. During this period, the resident experienced decreased level of consciousness and urine output, nausea, and vomiting, and was ultimately transferred to a hospital where ED labs showed cloudy urine with mucus, bacteria, and elevated red blood cells, and imaging identified a decompressed bladder with a Foley catheter in place. On the day of transfer, the Administrator inserted a Foley catheter to obtain a urine specimen despite the physician’s standing order for straight catheterization for specimen collection. The Foley catheter was left to drainage because a specimen could not be obtained. The resident was sent to the hospital with the Foley catheter in place due to a change in condition, including not opening eyes, not eating or drinking, and blood‑tinged urine. Hospital records documented that the Foley catheter was mispositioned, with the balloon partially inflated in the urethra, causing obstruction, hematuria, and infection. The resident required ICU care for septic shock secondary to Foley‑associated UTI and urosepsis in the setting of the mispositioned Foley catheter, with associated mild hydronephrosis and traumatic hematuria, and ultimately died; the death certificate listed sepsis and UTI as the cause of death, and the physician agreed that urosepsis could cause death. Additional deficiencies were identified in catheter care and incontinence care for several other residents. One resident with an indwelling Foley catheter and obstructive/reflux uropathy received catheter care from a CNA who entered the room under enhanced barrier precautions without performing hand hygiene or donning a gown, and who cleansed the groin, penis, and catheter tubing with soapy water but did not rinse or dry the resident. Another resident with a suprapubic catheter, chronic kidney disease, acute kidney failure, cystitis, and other comorbidities had orders for enhanced barrier precautions, routine suprapubic catheter site care, securement device changes, and barrier cream application. A CNA providing peri‑care and catheter care to this resident failed to don PPE despite an EBP sign, used the same soiled gloves throughout cleansing of the suprapubic site, groins, penis, and scrotum, did not apply the ordered cream, and did not secure the catheter, leaving it hanging freely. Further, residents with urinary incontinence and skin integrity issues did not receive complete incontinence care as ordered and per facility policy. One resident with moderate cognitive impairment, frequent bowel and bladder incontinence, and orders for enhanced barrier precautions and barrier cream was assisted to the toilet and wiped twice from front to back while standing, but the peri‑area and vagina were not cleansed, the soiled brief was pulled back up, no new brief was applied, no barrier cream was used on visibly reddened and slightly excoriated buttocks and anal area, and there was no hand hygiene or glove change between soiled and clean areas. Another resident with severe cognitive impairment, frequent incontinence, and a care plan for skin integrity and moisture management had a slightly wet brief removed during wound care, but no incontinence cleansing or new brief was provided, with the nurse stating she preferred to let the resident “air out.” In a separate observation, a resident dependent on staff for toileting hygiene and frequently incontinent of bowel and bladder had a saturated brief with urine and stool removed while standing; the CNA initially wiped visible stool with a wet towel, then left and returned with gloves and wipes, but only swiped from the back while the resident stood, without cleansing the inner thighs or buttocks or drying the area. These observed practices conflicted with the facility’s written policies on intermittent catheterization, urinary catheter care, perineal care, and suprapubic catheter care, which require verification of physician orders, proper specimen collection technique, documentation of urine characteristics and resident condition, and thorough cleansing, rinsing, and drying of the perineal and catheter areas using appropriate infection control measures. The policies also specify front‑to‑back cleansing for female residents, separate washcloths and water for labia and rectal areas, and proper care of suprapubic catheter sites to prevent skin irritation and urinary tract infection. The survey findings showed that these procedures were not consistently followed by staff during the provision of catheter care and incontinence care to the affected residents.
Failure to Use PPE and Hand Hygiene for Residents on Isolation and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring appropriate use of PPE, hand hygiene, and glove changes for residents on Contact Isolation and Enhanced Barrier Precautions (EBP). For one resident with an order for strict Contact Isolation due to abdominal wall cellulitis, a Contact Isolation sign and PPE were present on the door, yet a wound nurse (LPN) and a CNA entered the room to perform wound care without donning any PPE other than gloves. Before, during, and after the wound care, no additional PPE was worn. Another resident had a physician’s order for EBP, and an EBP sign with PPE was posted on the door. Two CNAs were observed assisting this resident with toileting and providing peri-care without donning the appropriate PPE prior to care. A third resident, care planned and ordered for EBP due to an indwelling medical device, had an EBP sign and PPE on the door. An LPN entered to fix the resident’s g-tube, which had become disconnected and was being held by the resident, and only donned gloves while reconnecting the tube and cleaning it with an alcohol pad. The LPN did not don gown or other PPE required under EBP and exited the room after doffing gloves without performing hand hygiene. A fourth resident with a physician’s order for EBP had an EBP sign and PPE on the door when a CNA entered to provide peri-care and catheter care. The CNA did not don PPE and used a single pair of gloves throughout the entire care episode, including obtaining wet washcloths from a water basin with soiled gloves, drying all cleaned areas, and then covering the resident with the sheet and blanket. The CNA did not change gloves or perform hand hygiene when moving from soiled to clean areas, including during catheter care. Staff interviews showed inconsistent understanding of EBP, with one CNA unable to recall what EBP meant, while the DON stated the expectation that staff don appropriate PPE for residents on EBP or isolation and perform hand hygiene before, during glove changes, and after care. These practices were inconsistent with the facility’s written policies on EBP, hand hygiene, transmission-based precautions, and infection control.
Failure to Follow Pressure Ulcer Treatment Orders and Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and to follow physician orders for a resident with existing pressure injuries. The resident had severe cognitive impairment, was dependent on staff for ADLs, and was frequently incontinent of bowel and bladder. The care plan identified altered skin integrity with a pressure ulcer and noted that wound healing could be hindered by the resident’s preference to lie on her back and noncompliance with turning every two hours. Interventions included regular turning/repositioning, maintaining clean and dry skin, minimizing moisture exposure, keeping linens dry and wrinkle-free, maintaining the head of bed at or below 30 degrees, weekly wound measurements, pain management, and reducing friction and shear. A physician order dated 3/4/26 directed cleansing and application of a hydrocolloid dressing to the right buttock every three days and as needed, but the TAR showed this treatment was only documented as completed on 3/4/26, then not again until 3/8/26 through 3/11/26, indicating missed treatments before the order was discontinued when the resident was hospitalized. After the resident returned from the hospital, new physician orders dated 3/17/26 directed application of moisture barrier with each incontinent episode to the peri area/buttocks and daily application of a dime-thick layer of Triad paste to bilateral buttocks, with documentation on the TAR showing daily completion from 4/1/26 through 4/14/26. During an observation of wound care, the wound nurse and a CNA entered the resident’s room, which had a contact isolation sign and PPE available, without donning PPE other than gloves. The nurse removed an undated hydrocolloid dressing from the coccyx/buttocks, poured normal saline over the wound, patted it dry with 4x4 gauze without cleaning or wiping the wound site, applied Triad paste, and left the resident without a dressing or incontinent brief, stating she liked to let the resident “air out.” The wound nurse later acknowledged that the hydrocolloid dressing should not have been in place because the order had been changed to Triad paste after the hospitalization, suggesting that another nurse had performed the wrong wound care. The IP and DON stated that nurses are expected to follow current physician orders, discontinue outdated orders in the TAR, and enter new orders so they are followed, consistent with the facility’s pressure wound treatment policy.
Failure to Timely Replace Broken CPAP Mask for Resident With Respiratory Disorders
Penalty
Summary
The deficiency involves the facility’s failure to timely replace a broken CPAP mask for a resident with significant respiratory conditions. Progress notes document that on one evening the resident complained of shortness of breath at bedtime, received a nebulizer treatment, and had an SpO2 that improved to 92%. The same note states the CPAP mask was broken and required replacement, and that the resident was placed on continuous oxygen at 4 L via nasal cannula. A subsequent progress note the next afternoon documents that the resident’s CPAP mask was broken and that the medical supply company would bring a new mask the following day, with oxygen at 3 L via nasal cannula in use while the mask was unavailable. The resident’s face sheet reflects diagnoses including COPD, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and obstructive sleep apnea. Physician orders include use of CPAP/BiPAP at nap time and at night to maintain oxygen saturation greater than 92%, and an order for oxygen at 3 L via nasal cannula if the resident refuses CPAP or if it is not available for any reason. The DON stated that when something is wrong with a mask, the medical supply provider is notified and the mask is sent out, sometimes the same day or the next day, and that if a resident with a history of respiratory failure has shortness of breath and no mask available, the physician should be notified. The medical supply provider reported that a CPAP mask was sent to the facility the day after the broken mask was documented. The facility’s CPAP/BiPAP policy describes the purpose of CPAP support for residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease and emphasizes comfort and safety, but the resident did not have a functioning mask as ordered during this period.
Failure to Administer Ordered Antibiotic and Other Medications as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to administer medications as ordered, including an antibiotic for a resident with a diagnosed urinary tract infection (UTI), and failure to follow physician orders for two residents. One resident (R21) had a chronic suprapubic catheter and urinary retention, with a care plan requiring maintenance of a closed catheter system and monitoring of urinary output and characteristics. After being sent to the hospital with decreased urination and a urinalysis consistent with UTI, R21 was treated with IV antibiotics and discharged back to the facility with an order for Cefdinir 300 mg every 12 hours for 10 days for UTI. The Medication Administration Record shows that from the time the order was written on 4/10/26 until 4/13/26, R21 received only one dose of Cefdinir, despite the order being active and the medication being available in the medication dispensing machine. The DON confirmed that the night shift nurse gave one dose from the machine but did not administer subsequent scheduled doses, and that the pharmacy had initially not sent the medication due to an allergy alert, yet nursing staff did not obtain the medication from the machine or promptly clarify the allergy with the physician until 4/13/26. In addition to the missed antibiotic doses, R21’s folic acid order was not followed correctly. A physician order dated 12/20/25, later re-ordered on 4/10/26, required folic acid 1 mg once daily at 6:00 AM. During an observation in R21’s room, surveyors noted a light yellow pill on the bedside table and two medicine cups containing creams, including a mixed cream that an LPN believed was intended for application to the resident’s bottom. The LPN stated that no medications had been given that morning because the resident’s medications were scheduled for 6:00 AM. Upon reviewing the medication cart, the LPN determined that the nurse had given stock folic acid 400 mcg instead of the resident’s prescribed folic acid 1000 mcg from the card, indicating that the resident did not receive the correct ordered dose. A second resident (R22), with multiple diagnoses including chronic kidney disease stage 4, dependence on renal dialysis, CHF, type 2 diabetes, seizures, and atrial fibrillation, had physician orders for Levetiracetam (Keppra) 500 mg. The orders specified dosing on Sunday, Tuesday, Thursday, and Saturday at 08:00 AM, and a separate order for 1000 mg (two 500 mg tablets) on Monday, Wednesday, and Friday at 08:00 AM. During medication pass, an LPN reported that R22 was supposed to receive Levetiracetam that day but did not receive it because the facility was out of the medication and it would not arrive from the pharmacy until the next day. The LPN told the resident she would have to wait until the following day for the dose. Subsequent staff interviews revealed that Keppra was available in the medication dispensing machine and that the nurse should have obtained it from there, documented the situation, and notified the physician, consistent with the facility’s medication administration policy. The policy requires that medications be administered as prescribed, that missing medications prompt a search of available supplies and contact with the pharmacy or use of emergency supplies, and that the five rights of medication administration be followed.
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.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 68 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jacksonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arcadia Care Jacksonville | 0.6 mi | ★★★★★ | 1 | 0 |
| Jacksonville Skld Nur & Rehab | 0.7 mi | ★★★★★ | 2 | 0 |
| Grove Health & Rehab Ctr, The | 1 mi | ★★★★★ | 18 | 1 |
| Cass County Senior Living & Rehabilitation Llc | 14.1 mi | ★★★★★ | 16 | 0 |
| Scott County Nursing Center | 18.4 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.