Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Prairieview Lutheran Home during CMS and state inspections, most recent first.
Two residents suffered fractures after staff failed to properly install wheelchair foot pedals, identify and address trip hazards from oxygen tubing and call light cords, and use appropriate transfer techniques following a fall. Staff observed hazards but did not intervene, and improper post-fall handling caused additional pain to an injured resident.
A resident with cancer diagnoses and significant weight loss did not receive a prescribed nutritional supplement three times daily due to the facility running out of stock. Nursing staff and the ancillary clerk confirmed the supplement was unavailable and no alternative was provided, as there was no physician order for a substitute. The resident continued to experience poor intake and weight loss, and there was no documented communication with the physician or dietitian to address the lack of supplement.
A resident with multiple comorbidities and on anticoagulant therapy was not thoroughly assessed or monitored after a fall and during transfers with a sit-to-stand lift. Staff failed to document or measure bruising progression, did not assess the appropriateness of the lift, and did not communicate the full extent of injuries to the physician. The resident developed a severe arterial bleed and extensive bruising, ultimately leading to hospitalization and death.
The facility did not provide required training on the Quality Assurance and Performance Improvement (QAPI) Program to all staff, as neither the facility assessment nor the staff education system included QAPI as a training topic. Interviews and record reviews confirmed that QAPI training had not been completed since 2020, affecting all 84 residents.
The facility did not ensure that physician progress notes were documented and signed for multiple residents, despite LPN documentation of physician evaluations. The DON stated that physician notes are sometimes missing from the EMR and must be requested, and the physician confirmed that notes are not always completed at the time of visit.
A resident with a history of requiring a sit-to-stand lift was found with extensive bruising and later required emergency intervention for an arterial bleed. The facility's investigation was incomplete, as only a limited number of staff were interviewed, key questions about the cause of injury and possible falls were not addressed, and video review was insufficient. The investigation did not meet the facility's policy requirements for determining the cause of injuries of unknown origin.
A resident who required one-person assist and a gait belt for transfers experienced a fall during a transfer when staff failed to use a gait belt as specified in the care plan and assessment. The incident was not thoroughly investigated, as no incident report or fall investigation packet was completed, despite facility policy requiring such actions. The resident had a history of falls and was cognitively intact at the time.
A resident with severe cognitive impairment and high fall risk was injured after being propelled in a wheelchair without foot pedals, resulting in a fall and facial lacerations requiring sutures. The facility did not have a process to assess the need for foot pedals and failed to implement care plan interventions such as keeping the bed in the lowest position and placing a safety mat, as required.
A resident with severe cognitive impairment and high fall risk experienced multiple unwitnessed falls from an electric lift chair, resulting in a femoral neck fracture and subsequent death. The facility did not identify the lift chair as a hazard, failed to ensure chair alarms were properly connected, and did not implement or document post-fall interventions or thorough investigations, despite existing care plans and fall prevention policies.
A resident who suffered a fall with a major injury, including a cervical spine fracture after being pushed in a wheelchair, was not accurately documented in the subsequent MDS assessment. The assessment failed to record the fall and injury, an error later confirmed by the MDS Coordinator.
A CNA shared the first names and details about the care of three cognitively impaired residents with an unauthorized individual, violating confidentiality policies and residents' rights to privacy. The breach was confirmed through investigation and staff interviews.
A resident with multiple sclerosis and chronic pain did not receive adequate pain management due to the facility's failure to schedule a pain clinic appointment for a pain pump refill. Despite the resident's reliance on the pump and the care plan's directives, there was a lack of documentation and follow-up, resulting in the resident experiencing inadequate pain relief. Interviews revealed communication breakdowns among staff, contributing to the deficiency.
The facility failed to maintain accurate medical records for two residents. One resident's physician progress notes were missing for three months, with unsigned and incomplete SOAP notes. Another resident's progress notes contained incorrect vital sign dates. The DON and Administrator confirmed these documentation errors.
A facility failed to accurately obtain and report the weights of a resident who was under a physician's order for daily weights. The resident experienced an 11.46% weight loss over a period, which was not reported to any staff member. The facility's policy requires significant weight changes to be re-verified and reported to a physician, but this was not done. A Licensed Dietician noted that weights should be consistent and any differential should be reported for follow-up.
A resident with severe cognitive impairment and multiple health issues had 60 tablets of Hydrocodone misappropriated in an LTC facility. The incident was discovered when a nurse contacted hospice for a refill and found discrepancies in medication counts. The facility suspects an agency RN of the theft.
A facility failed to maintain accurate narcotic administration records for a resident with multiple diagnoses, including Alzheimer's and Dementia. The resident was prescribed Hydrocodone for pain, but a dose administered was not documented on the medication count sheet as required by the facility's policy. This omission was confirmed by the DON, highlighting a deficiency in narcotic record-keeping.
A resident with severe cognitive impairment and multiple medical conditions fell from a mechanical lift during a transfer, resulting in a hip fracture that required emergency surgery. The fall occurred when one of the sling straps slipped free, highlighting a failure in providing safe and effective supervision.
Failure to Prevent Accident Hazards and Provide Safe Supervision
Penalty
Summary
The facility failed to ensure that accident hazards were removed and that adequate supervision was provided to prevent accidents, resulting in significant injuries to two residents. In one instance, a resident was pushed in a wheelchair by her Power of Attorney during an outdoor event without the foot pedals properly installed. The foot pedals were off to the side, leaving the resident's legs exposed and unsupported. Staff observed the improper use of the wheelchair foot pedals but did not intervene or provide assistance. As a result, the resident's foot became caught when transitioning from pavement to grass, leading to a fall and a left leg fracture. In another case, a resident with a history of falls and requiring assistance for transfers attempted to go to the bathroom independently during the night. The resident tripped over oxygen tubing and a call light cord that were stretched across the room, both identified as environmental trip hazards. The resident fell and sustained a right hip and right arm fracture. Staff interviews confirmed that the room setup contributed to the fall, as the cords were not secured or arranged to prevent tripping. Following the fall, staff did not use appropriate transfer techniques to move the injured resident. Instead of using a full mechanical lift or waiting for emergency services, staff lifted the resident by her shoulders and legs, causing her to scream in pain. This method of transfer was not in accordance with proper post-fall procedures, especially given the resident's injuries and inability to bear weight. The facility's failures in identifying and addressing environmental hazards, as well as improper transfer techniques, directly resulted in harm to the residents.
Failure to Provide Physician-Ordered Nutritional Supplement
Penalty
Summary
A deficiency occurred when the facility failed to provide a physician-ordered nutritional supplement to a resident with a history of significant weight loss and malnutrition. The resident, who had diagnoses of malignant neoplasm of the right lower lung and small cell B-cell lymphoma, was prescribed a 237 ml bottle of a nutritional supplement three times daily due to poor intake and a documented 10-pound weight loss in one month. Despite this order, the resident reported only occasionally receiving the supplement, and nursing documentation confirmed that the supplement was not available to be given as ordered on multiple occasions. The resident was observed to be thin with visible bony prominences, and her weight continued to decline over several months. The facility's staff, including an LPN and the ancillary clerk responsible for ordering supplies, confirmed that the ordered supplement had been out of stock since the previous day and that no alternative supplement was provided because there was no physician's order for a substitute. The storage room contained other nutritional supplements, but none matching the resident's order. There was no documented communication with the physician or dietitian to obtain an alternative order during the period the supplement was unavailable. The DON stated that nurses should contact the physician for an alternative if a supplement is unavailable, but this was not done in this case.
Failure to Assess and Monitor Resident After Fall and Mechanical Lift Use
Penalty
Summary
The facility failed to properly assess, monitor, and evaluate a resident following a fall and during the use of a mechanical sit-to-stand lift, resulting in a delay in treatment for an arterial bleed. The resident, who had a complex medical history including Alzheimer's disease, morbid obesity, osteoarthritis, a history of falls, and was on anticoagulant therapy, was totally dependent on staff for all activities of daily living and was severely cognitively impaired. After a fall, staff documented complaints of hip pain and some bruising, but did not provide thorough or ongoing assessments, including measurements or detailed documentation of the bruises. There was also no documented assessment for the safe and appropriate use of the sit-to-stand lift for this resident. Over the following days, staff observed increasing bruising and changes in the resident's condition, including shortness of breath, pallor, and further extension of bruising, but failed to promptly escalate care or reassess the situation in a timely manner. Communication between staff and the physician was inadequate, with the physician not being fully informed of the extent of the bruising and the resident continuing to receive anticoagulant medication. Staff also did not consistently document or measure the progression of the bruising, and there was a lack of clear documentation regarding the appropriateness of the mechanical lift for the resident's condition. The resident's condition deteriorated, with significant bruising and a drop in hemoglobin, eventually requiring emergency hospital care for a large subcutaneous hematoma and arterial bleed. The injury was determined by a hospital interventional radiologist to be consistent with trauma from a sit-to-stand lift. The resident ultimately died from complications related to blood loss anemia due to the chest wall hematoma. Staff interviews revealed uncertainty about the cause of the injury, lack of proper assessment protocols, and failure to communicate changes in the resident's condition effectively.
Removal Plan
- Nursing leaders and Administration will review a plan to remediate the Immediate Jeopardy.
- A Lift Assessment will be conducted on all residents who require the use of a mechanical lift, completed by the Restorative Nurse and Therapy Staff.
- Education will be provided to the nursing staff regarding the use of mechanical lifts and the new assessment process; all staff working the floor will be required to sign off on the in-services and staff not in attendance will be contacted to complete the in-service.
- If a CNA feels the lift process is unsafe, the CNA will report this to the charge nurse, who will assess and may downgrade the mechanical lift; this will then be reviewed by DON / ADON / Restorative Nurse / and Therapy.
- The Restorative Nurse will obtain Certification of Restorative Nursing; Therapy Staff will oversee Restorative Nursing programs until certification is obtained.
- Policies are being updated regarding the monitoring of bruising for all residents on anti-coagulant therapy: if a new bruise is identified, the MD will be notified and the nurse on duty will monitor and reassess the bruise; measurements will be taken and recorded; any signs of the bruise increasing in size will be reported to the MD; a Progress Note will be completed to include measurements, vital signs, and a description of the bruising and/or change of condition.
- The TAR was updated for all residents on anti-coagulant medication to observe for adverse reactions.
- The Lift Assessment will be completed for all residents who need a mechanical lift upon admission, or as needed if their transfer status is changed, by the Restorative Nurse and Therapy Staff.
- Following a change in lift status, DON / ADON / Restorative Nurse or Designee will monitor and reassess.
- If a resident shows signs of bruising and is on an anti-coagulant, the MD will be notified and the nurse on duty will monitor and reassess the bruise; if bruising increases and/or there are signs of a change in condition, the MD will be notified.
- All above education will be provided by the Education Nurse for all new hires.
- Random audits on mechanical lift transfers will be conducted by Nurse Leadership.
- Random audits on nursing documentation regarding residents on anti-coagulant medications will be completed by nursing leaders to ensure proper orders are in place and appropriate follow-up for signs/symptoms of adverse reactions are documented.
- Lift Assessments and Transfer Status will be added to the IDT QA reporting for review, presented by the Restorative Nurse and/or Therapy.
- Any injuries noted in relation to a transfer with a mechanical device will be reviewed in the QA meeting with the IDT, presented by the IDT Nurse Leaders.
- Residents on anti-coagulants and with new bruising will be added to the IDT QA reporting for review by the IDT Nursing Leaders.
- Any incidents regarding the monitoring of residents on anti-coagulant medications will be reviewed at the QA meeting with the IDT and presented by the IDT Nurse Leadership.
Failure to Provide Mandatory QAPI Training to All Staff
Penalty
Summary
The facility failed to ensure that all staff received training on the Quality Assurance and Performance Improvement (QAPI) Program, as required. The facility assessment reviewed on 9/26/25 did not include QAPI training as a topic for staff education, either upon hire, annually, or during new employee orientation and in-services. During interviews and record reviews, the Human Resources representative confirmed there was no documentation of QAPI training in the web-based training and education system, nor was it part of the orientation process. Further, it was confirmed by both Human Resources and the Nurse Educator that QAPI training had not been completed since 2020. At the time of the survey, the facility had a census of 84 residents.
Physician Progress Notes Not Documented in Resident Records
Penalty
Summary
The facility failed to ensure that the physician documented and signed progress notes for each required visit for five out of six residents reviewed for physician visits. For each of these residents, the face sheet identified the same primary physician, and progress notes recorded by an LPN indicated that the physician evaluated the residents on multiple occasions. However, as of the date of review, the electronic medical records for these residents did not contain any physician progress notes corresponding to those visits. During interviews, the Director of Nursing explained that physician visit notes are either documented under assessments or uploaded into the EMR's miscellaneous section, but sometimes the facility must request the physician to send the notes. At the time of the survey, the physician's progress notes for the affected residents were not available in the EMR, and the physician acknowledged that while they attempt to document notes at the time of each visit and complete them during office days, this does not always occur.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who was found with significant bruising to the sternum, right breast, and under the right arm, accompanied by pain and limited range of motion. The resident, who required a sit-to-stand lift for transfers, was later found to have additional bruising, shortness of breath, chest pain, and a critically low hemoglobin level, necessitating emergency medical intervention for an active arterial bleed. There was no reported fall or clear mechanism of injury, and the bruising was noted to be in areas consistent with the use of the stand lift sling, although staff stated that the lift should not cause such injuries. The facility's investigation into the incident was incomplete. Only four staff interview forms were included in the investigative file, and these forms lacked signatures and did not document whether staff were asked about the cause of the bruising, possible falls, or details about the use of the lift. Interviews with staff revealed that the resident disliked the stand lift and sometimes expressed pain during its use, but no staff could identify a specific incident that led to the injury. The investigation did not include interviews with all staff who worked with the resident during the relevant period, nor did it include a comprehensive review of video surveillance beyond a single activity session. The facility's policy requires a root cause investigation and analysis for injuries of unknown source, including gathering statements from all involved staff and witnesses, as well as a description of the resident's behavior and environment at the time of the incident. However, the investigation did not meet these requirements, as it failed to determine the cause of the injury or rule out abuse, and did not document a thorough review of all possible contributing factors or staff involvement.
Failure to Use Gait Belt and Investigate Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to safely transfer a resident, resulting in a fall, and did not conduct a thorough investigation of the incident. The resident, who was cognitively intact and required partial to moderate staff assistance for chair/bed transfers, had a documented history of two or more falls without injury. The resident's care plan and functional mobility assessment specified the use of a gait belt and one-person assist for transfers, along with the use of grab bars or a walker. During the incident, the resident was being assisted into bed from a wheelchair by a CNA, who did not use a gait belt as required. The resident let go of the bed rail to adjust his pants, lost balance, and was assisted to the floor, sustaining no injuries. Following the fall, there was no documentation of a thorough investigation. The nursing note recorded the fall, but an incident report and a fall investigation packet were not completed. The CNA involved confirmed that a gait belt was not used during the transfer, despite the resident's care plan and assessment indicating its necessity. The facility's policy on managing falls requires staff to implement and monitor individualized fall prevention interventions and to re-evaluate interventions if falls continue, but there was no evidence that these procedures were followed in this case.
Failure to Ensure Wheelchair Safety and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure resident safety by not placing foot pedals on a resident's wheelchair while the resident was being propelled by staff. This omission resulted in the resident placing her feet on the floor and falling forward out of the wheelchair, causing significant facial lacerations that required eleven sutures. The incident occurred despite the resident having a documented history of high fall risk, severe cognitive impairment, and dependence on staff for mobility and personal care. Staff interviews confirmed that there was no facility-wide policy or process to assess the need for foot pedals when residents were being propelled, and a similar incident had occurred with another resident in the past without subsequent changes to practice. Additionally, the facility failed to implement fall prevention interventions as outlined in the resident's care plan. The care plan specified that the resident's bed should be in the lowest position and a safety mat should be placed on the left side of the bed. However, observations revealed that the bed was not in the lowest position and the safety mat was not in place, contrary to both the care plan and physician orders. Staff and administrative interviews confirmed that these interventions were still current and required for the resident. Multiple staff members, including nursing, housekeeping, and family members, were observed propelling residents in wheelchairs without foot pedals, with residents holding their feet up off the floor. The lack of a standardized assessment or policy regarding the use of foot pedals contributed to the unsafe environment and directly led to the resident's fall and injury. The facility's inaction following a previous similar incident further demonstrates the ongoing failure to address this safety hazard.
Failure to Identify and Address Electric Lift Chair as Fall Hazard
Penalty
Summary
The facility failed to identify an electric lift chair as a fall hazard, did not develop or implement appropriate post-fall interventions, and did not thoroughly investigate falls for a resident with severe cognitive impairment and a high risk for falls. The resident required substantial to maximal assistance for mobility and had a care plan that included interventions such as a silent recliner alarm, nonskid mat, and standby assist for transfers. Despite these interventions, the resident experienced multiple unwitnessed falls from the electric lift chair, with documentation indicating that the chair alarm was not properly connected and the lift chair remote was within the resident's reach. After one fall, the resident was found on the floor in front of the recliner, which was in a forward tilt position, and was unable to recall the incident. There was no documentation of post-fall interventions for this event. In a subsequent fall, the resident was again found on the floor in front of the electric lift chair, which was fully elevated, and the alarm was not plugged in to activate the call light. The investigation did not identify the root cause of the fall, did not document whether the nonskid mat was in place, and did not assess the lift chair as a potential hazard. The facility's staff interviews confirmed uncertainty about alarm function checks and the placement of the chair remote, and the facility lacked a policy or assessment process for the use of electric lift chairs. The resident sustained a nondisplaced left femoral neck fracture requiring surgical repair following the second fall and subsequently passed away. The facility's fall management policy required individualized fall prevention plans and monitoring of interventions, but there was no evidence that the facility re-evaluated or changed interventions after repeated falls, nor that the electric lift chair was considered as a contributing factor.
Inaccurate MDS Assessment Following Resident Fall with Major Injury
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident who experienced a fall with major injury. The resident was pushed in a wheelchair by a Certified Nursing Assistant, during which the resident's feet became caught under the wheelchair, resulting in a fall and head injury. The resident subsequently complained of neck pain, had elevated blood pressure, and was transferred to the hospital, where a cervical spine fracture was diagnosed and a cervical collar was prescribed. Despite these events, the MDS assessment completed after the incident did not document the fall or the major injury, as confirmed by the MDS Coordinator, who acknowledged the omission and was unsure how the error occurred.
Breach of Resident Confidentiality by CNA
Penalty
Summary
The facility failed to protect the privacy and confidentiality of residents' personal and medical records for three residents diagnosed with Alzheimer's Disease, all of whom were severely cognitively impaired and required staff assistance for all activities of daily living. The deficiency occurred when a Certified Nurses Assistant (CNA) shared residents' first names and details about her workday, which included information about these residents, with her boyfriend, who was not authorized to receive such information. This breach was discovered when the boyfriend alerted the facility about the disclosures. During the investigation, the CNA admitted to discussing her day and mentioning residents' first names to her boyfriend. Facility staff, including the Memory Care Director and Human Resources, confirmed that the CNA had shared this information, which was considered a violation of the facility's confidentiality policies and the residents' right to privacy. The facility's documentation and interviews with staff substantiated that the CNA's actions led to the breach of confidentiality for the three residents.
Failure to Schedule Pain Pump Refill Leads to Inadequate Pain Management
Penalty
Summary
The facility failed to ensure adequate pain management for a resident who relied on a surgically implanted pain pump for relief from chronic pain associated with multiple sclerosis and other conditions. The resident, who was cognitively intact, reported that the pain pump had not been refilled for months, leading to inadequate pain relief despite the use of oral pain medications. The resident's care plan included interventions to notify the physician for increased or uncontrolled pain and to follow up with the pain clinic for pump refills, but these interventions were not effectively implemented. The deficiency was further highlighted by the lack of documentation and follow-up regarding the scheduling of a pain clinic appointment for the resident's pain pump refill. The resident's social service note indicated that an appointment had been canceled, and the facility's scheduler was aware of the need to reschedule. However, there was no documentation of further attempts to secure an appointment, and the resident continued to experience inadequate pain management. Interviews with facility staff revealed a breakdown in communication and follow-up. The Director of Nursing was unaware of the delay in scheduling the appointment, and the Certified Nursing Assistant responsible for scheduling acknowledged not having documented any attempts to contact the pain clinic. This lack of coordination and communication resulted in the resident not receiving the necessary pain management services, as outlined in the facility's pain management policy.
Inaccurate and Incomplete Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, R1 and R25, as per their policy on charting and documentation. For R1, the facility did not have the physician's progress notes for the last three months, and the SOAP notes made by the nursing department were unsigned and lacked a full assessment of R1's past medical history, current status, diagnoses, medications, or review of systems. The Director of Nursing confirmed that the Medical Director assessed R1 monthly, but the documentation was incomplete and unsigned until a later date. For R25, the physician progress notes for three separate dates contained incorrect vital sign information, with all vital signs having a November date instead of the actual assessment dates. The Administrator confirmed that the effective dates on the progress notes were the dates the assessments were completed, but the vital sign information was not accurate for those dates. This indicates a failure to document accurate and timely medical information for the residents, which is essential for effective communication and care planning.
Failure to Accurately Monitor and Report Resident's Weight Loss
Penalty
Summary
The facility failed to accurately obtain and report the weights of a resident, identified as R25, who was under a physician's order for daily weights on specific days. The resident's Electronic Medical Record (EMR) showed inconsistent methods of obtaining weights, including standing, sitting, and wheelchair measurements. Between October 4, 2024, and November 11, 2024, R25 experienced an 11.46% weight loss, dropping from 107 pounds to 96 pounds. This significant weight loss was not documented as being reported to any staff member. The facility's policy requires that significant weight changes or questionable weights be re-verified and reported to a physician if there is a 5% weight change in one month. However, this protocol was not followed for R25. On November 13, 2024, a Licensed Dietician, identified as V13, stated that weights should be consistent, using the same scale, at the same time of day, and with similar clothing. V13 also mentioned that any weight differential should be reported to a nurse for follow-up. The facility's failure to adhere to these guidelines and report the significant weight loss of R25 constitutes a deficiency in maintaining the resident's health through proper monitoring and reporting of weight changes.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse by not preventing the misappropriation of the resident's narcotic pain medication. The incident involved a resident diagnosed with Alzheimer's Disease, Dementia, Behavioral Disturbance, Mood Disturbance, Anxiety, Seizures, Major Depressive Disorder, Heart Disease, and Muscle Weakness, who was under hospice care and prescribed Hydrocodone-Acetaminophen for pain management. The facility's policy defines abuse to include the misappropriation of resident property, which occurred when 60 tablets of the resident's Hydrocodone went missing, along with the corresponding Controlled Drug Received/Record/Disposition Form. The incident was discovered when a registered nurse contacted hospice for a refill of the medication and was informed that a refill had already been delivered. An investigation revealed discrepancies in the narcotic medication count conducted by different nurses, indicating that the medication and form were missing. The facility believes that an agency registered nurse is the alleged perpetrator of the theft. The administrator confirmed the loss of the medication and the form, which has not been recovered.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to accurately maintain narcotic administration records for a resident diagnosed with Alzheimer's Disease, Dementia, Behavioral Disturbance, Mood Disturbance, Anxiety, Seizures, Major Depressive Disorder, Heart Disease, and Muscle Weakness. The resident was prescribed Hydrocodone-Acetaminophen to be taken four times a day for pain management. According to the facility's Controlled Substances policy, narcotic medications should be reconciled upon receipt, administration, disposition, and at the end of each shift. The nurse administering the medication is responsible for recording the time, method, quantity remaining, and their signature. However, the administration of Hydrocodone to the resident on a specific date at 2:00 AM was not documented on the Controlled Drug Received/Record/Disposition Form, which serves as the medication count sheet. This omission was confirmed by the Director of Nurses, who acknowledged that the dose should have been recorded on the resident's narcotic medication count sheet. The failure to document the administration of the narcotic medication as per the facility's policy led to the deficiency identified in the report.
Failure to Provide Safe Supervision During Transfer
Penalty
Summary
The facility failed to provide safe and effective supervision during a transfer, resulting in a traumatic fall for a resident. The resident, who had severe cognitive impairment and was completely dependent on staff for all activities of daily living, fell from a mechanical lift when one of the four main straps attaching the sling to the lift slipped free. This incident caused the resident to fall to the ground, striking their left hip on the metal frame of the lift, leading to a hip fracture that required emergency medical treatment and surgical repair. The resident's medical history included muscle weakness, paraplegia, cerebral infarction, osteoarthritis, presence of an artificial knee joint, apraxia, dementia, major depression disorder, and anxiety disorder. The incident report and investigation revealed that two certified nurse aides were involved in the transfer when the fall occurred. The aides reported that the resident was elevated in the air above their chair when the top left sling loop became free, causing the fall. The resident experienced significant pain and was administered fentanyl by emergency medical technicians before being sent to the hospital. The hospital's emergency department confirmed the hip fracture and performed orthopedic surgery. The facility conducted an in-service training for staff on the proper use of mechanical lifts following the incident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 35 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Danforth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gilman Healthcare Center | 5.4 mi | ★★★★★ | 0 | 0 |
| La Bella At Clifton | 7.9 mi | ★★★★★ | 0 | 0 |
| Piper City Rehab & Living Ctr | 11.6 mi | — | 0 | 0 |
| Iroquois Resident Home, The | 13.6 mi | ★★★★★ | 0 | 0 |
| Arcadia Care Watseka | 13.7 mi | — | 16 | 0 |
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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.