Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Estates during CMS and state inspections, most recent first.
A resident’s toilet seat was observed broken and not securely attached on one side after the resident said it had been broken for about a week. The resident reported telling an aide and a nurse, but no repair was documented in the maintenance log, and an LVN, CNA, Maintenance Director, and Maintenance Assistant all confirmed they had not been aware of the issue until later. The resident said he was afraid to sit on the toilet because he did not want to fall.
Missing Colostomy Care Plan: A resident with paraplegia, MS, and a colostomy had a care plan that did not include the colostomy, even though the MDS and orders reflected the need for ongoing colostomy care. The MDS Nurse, ADON, and DON stated the item may have been dropped during a computer system change, and nursing management was responsible for ensuring the care plan was accurate and implemented.
A resident receiving IV Ceftriaxone for a UTI had a PICC line and an IV bag hanging without the bag or tubing labeled with the date, time, and initials. The assigned LVN stated she administered the antibiotic but forgot to label it, and the ADON, DON, and facility IV therapy policy all required IV tubing to be dated, timed, and initialed.
Expired Medications Left on Medication Carts Surveyors found expired and undated medications on two medication carts, including a Calcium/Vit D supplement, Clonidine, and Tums. The MA responsible for one cart said she checked for expired meds only every couple of days, while the RN responsible for the other cart said she checked daily but missed the expired meds. The ADON and DON described weekly cart checks, and the facility policy required staff to identify expiration dates and notify the nurse manager if expired.
An LVN left an oxycodone-acetaminophen tablet in a resident’s medicine cup on the over-bed table and walked out without observing the dose being taken. The resident had dementia, psychotic and mood disorders, anxiety, and schizoaffective disorder, and the record did not show self-administration orders or documentation. The resident said staff had left his meds at bedside before, while the LVN acknowledged the policy was to watch residents take meds before leaving the room.
A resident with severe cognitive impairment, multiple complex diagnoses (including pneumonia, CKD stage 4, MRSA pneumonia, malnutrition), dysphagia, and a mechanically altered diet did not have a comprehensive, person-centered care plan reflecting her evolving medical and dietary needs. The written care plan addressed only pressure ulcer risk and antibiotic therapy and omitted dysphagia, aspiration risk, supervision during meals, respiratory issues, pneumonia treatment, and textured diet/aspiration precautions ordered after hospitalizations. Interviews with the RNC, DON, and MDS nurse showed that although facility policy and practice required acute and updated care plans after readmissions and condition changes, staffing gaps in the MDS department and failure to complete acute care plans and updates led to the resident’s repeated hospitalizations, diet changes, and therapy needs not being incorporated into the care plan.
A resident with multiple health conditions and recent denture placement did not have dental or oral health needs addressed in her care plan, despite documented dental issues and instructions from the dentist. The resident reported problems with her dentures and a broken tooth to staff, but no interventions or follow-up occurred, and staff interviews revealed a lack of awareness about her dental care needs.
A resident with multiple health conditions did not receive necessary dental care after receiving new dentures, as follow-up appointments were missed and no further attempts were documented. The resident reported ill-fitting dentures and a broken tooth, but staff did not arrange for adjustments or repairs. The contracted dental provider placed a 'do not treat' status on the resident's account due to incomplete re-enrollment paperwork, specifically a missing physician-signed form, which prevented further dental services.
A resident with an indwelling catheter experienced increased pain and discomfort due to the facility's failure to adhere to physician orders for catheter care and timely notification of the NP. The resident's catheter was not changed as scheduled, and there was a lack of documentation. Despite the resident's complaints, the nurse delayed notifying the NP, leading to a risk of infection.
The facility's kitchen failed to meet professional standards for food safety, with observations of improperly stored raw chicken and ham, and spoiled bananas on a prep table. The Dietary Supervisor confirmed these issues, acknowledging that the food should have been sealed and spoiled items discarded, as per the facility's policy and FDA guidelines.
A resident with severe cognitive impairment and a diagnosis of schizophrenia did not receive a required PASRR level 2 evaluation due to an incorrect PASRR level 1 screening. Facility staff were unaware of the discrepancy, and the MDS nurse mistakenly believed the resident's dementia diagnosis negated the need for further evaluation.
A facility failed to ensure proper treatment for a resident with a G-tube, as LVN A did not verify tube placement by aspirating stomach contents before administering medications and water flushes. The resident, who was non-verbal and had severe cognitive impairment, was dependent on enteral feeding due to dysphagia. The facility's policy requires checking tube placement and gastric contents, which LVN A admitted to forgetting. The DON confirmed the need to follow the facility's policy after reviewing it.
A resident on enhanced barrier precautions was assessed by an LVN who failed to don full PPE, as required by the facility's infection control policy. Despite being aware of the precautions, the LVN only wore gloves while handling the resident's foley catheter, risking cross-contamination. The DON confirmed staff training on PPE use, highlighting the breach in protocol.
The facility failed to complete baseline care plans within 48 hours for two residents, one with a leg fracture and another with a femur fracture and COPD. Staff were unaware of the required timeframe and relied on an electronic system for notifications, which may have malfunctioned. Despite the delay, staff believed care was not compromised due to effective communication.
A facility failed to maintain accurate clinical records for a resident prescribed psychotropic medications without documented diagnoses. The resident, with severe cognitive impairment, was on medications like Haloperidol for agitation, but the diagnosis was incorrect. The DON confirmed the necessity of the medication due to the resident's behaviors and failed dose reductions. The resident denied mental health diagnoses, highlighting discrepancies in documentation.
A facility failed to obtain proper consent from a cognitively impaired resident for sharing information with an affiliated insurance company. The resident's responsible parties were unaware of any consent given, and a staff member admitted to falsifying consent forms under pressure to increase referrals. This violated the facility's policy on resident rights.
The facility failed to maintain clean wheelchairs for two residents, with observations showing significant dirt and debris buildup. Staff interviews revealed inconsistencies in cleaning procedures and responsibilities, with no set schedule for deep cleaning and inadequate documentation of cleaning requests.
Broken Toilet Seat Not Repaired
Penalty
Summary
The facility failed to ensure a resident had a safe, clean, comfortable, and homelike environment when Resident #14’s toilet seat was found broken and not securely attached on the left side. During observation and interview, the resident stated the toilet seat had been broken for about a week and said he had told an aide and a nurse about it, but was told someone would come fix it and no one did. The resident also stated he was scared to sit on the toilet because he did not want to fall and hurt himself, although he reported no fall or injury had occurred. When staff were interviewed, an LVN and CNA stated the resident took himself to the bathroom and did not need assistance, and both said the resident had never told them the toilet seat was broken. They confirmed the toilet seat was broken after going to the bathroom. Review of the maintenance log for March 2026 did not show a request to repair the toilet seat. The Maintenance Director stated he had not heard about the broken toilet seat and explained that staff were supposed to enter repair needs in the maintenance book at the nurse’s station. The Maintenance Assistant said he first heard about the broken toilet seat later that day and did not see an entry in the maintenance book. The Administrator stated staff were expected to enter repair needs in the maintenance book as soon as they became aware of them, and that broken items in resident rooms could potentially cause injury.
Missing Colostomy Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #24 that included measurable objectives and timeframes to meet the resident’s identified needs. Resident #24’s quarterly MDS reflected diagnoses of paraplegia, multiple sclerosis, and attention to colostomy, and also indicated a BIMS score of 15 with intact cognition. However, the care plan initiated on 10/30/24 did not reflect that the resident had a colostomy, even though the Order Summary Report for March 2026 directed staff to check placement and empty the colostomy contents every shift and more often as necessary. During observation on 03/26/26, Resident #24 was sitting in a wheelchair, alert and pleasant, and the colostomy site was clean, with no redness and no signs of infection. RN G stated there had never been any issues or concerns with the resident’s colostomy site. The MDS Nurse stated she was not aware the colostomy status was missing from the care plan and said the status had been on the previous computer system before the facility switched to a new system in November 2025, after which it appeared not to have transferred over. The ADON and DON both stated they were not aware the colostomy status was not on the current plan and indicated that nursing management and the MDS Nurse were responsible for ensuring care plans were accurate and implemented.
IV Antibiotic Bag and Tubing Not Labeled
Penalty
Summary
Facility staff failed to ensure parenteral fluids were administered in accordance with physician orders, the resident’s care plan, and professional standards of practice for Resident #137. Resident #137 was an [AGE] year-old female admitted to the facility with diagnoses including chronic respiratory failure with hypoxia, hyperlipidemia, non-Alzheimer’s dementia, and anxiety disorder. Her BIMS score was 13, indicating intact cognition. Her care plan addressed antibiotic therapy for a UTI/elevated WBC, and a physician order directed Ceftriaxone Sodium Solution Reconstituted 1 gram intravenously once daily for 7 days. During observation, Resident #137 was sitting in her wheelchair with a PICC line in her left arm and a dressing dated [DATE], with no redness or drainage noted. The IV medication bag was hanging on the pole, and the IV tubing was not labeled with the date, time, and initials. Resident #137 stated she received her antibiotics at nighttime. The assigned LVN stated she administered the antibiotics and acknowledged the bag was missing the time, date, and initials because she got busy and forgot to label it. The ADON and DON both stated staff were expected to date and initial the medication bag and tubing when administering IV medication, and the facility IV therapy policy stated all IV tubing is to be labeled with date, time, and initials.
Expired Medications Found on Medication Carts
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring expired medications were removed from 2 of 5 medication carts reviewed. On the Hall 100 medication aide cart, surveyors observed one bottle of Calcium 500 mg/Vitamin D 400 unit with an expiration date of December 2025. On the Hall 900 nurses' medication cart, surveyors observed one bubble pack of Clonidine 0.1 mg with an expiration date of 02/24/26 and one bottle of Tums with no expiration date. During interviews, the Medication Aide stated she was responsible for checking her cart for expired medications but had not checked it on the day of the observation and only checked every couple of days. The RN responsible for the Hall 900 cart stated she had checked the cart that morning but missed the expired medication and said she checked daily for expired medications and expiration dates. The ADON stated nurses were expected to check their carts weekly and that ADONs were responsible for checking behind the nurses weekly, while the DON stated all nurses were responsible for checking their carts weekly to ensure expired medications were removed. Facility training records showed RN G attended cart audit training, and the facility Medication Administration policy dated 02/01/25 stated to identify the expiration date and, if expired, notify the nurse manager.
Medication Left Unattended at Bedside
Penalty
Summary
The facility failed to ensure that Resident #19’s Oxycodone-Acetaminophen tablet was not left unattended on the resident’s over-bed table during medication administration. Resident #19 was a [AGE]-year-old male with diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, chronic ischemic heart disease, and schizoaffective disorder. His quarterly MDS showed a BIMS score of 15 with memory intact, and the record did not include documentation for self-administration of medication or physician orders allowing self-administration. During observation, an LVN placed a medicine cup containing a pill on Resident #19’s over-bed table and left the room without ensuring the medication was taken. In interview, the resident stated staff had left his medication at bedside before because they knew he would take it. The LVN stated she was aware of the policy to observe residents take medications before leaving the room but could not explain why she left the pill unattended. The DON stated the facility policy was that no medications are to be left at the resident’s bedside, and the ADM stated staff were expected to follow the medication administration policy.
Failure to Maintain Comprehensive, Person-Centered Care Plan After Hospitalizations and Diet Changes
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple complex medical conditions. The resident, an elderly female, had numerous diagnoses including lobar pneumonia, acute kidney failure, gout, mononeuropathy, diabetes, malignant neoplasm, metabolic encephalopathy, anemia, stage 4 chronic kidney disease, MRSA pneumonia, and malnutrition. Her 5-day admission MDS showed a BIMS score of 5 indicating severe cognitive impairment, range of motion impairment, wheelchair use, need for supervision or touching assistance with eating, and a mechanically altered/therapeutic diet with high-risk medications. She also had orders for skilled speech therapy for cognitive-linguistic deficits and dysphagia management, and a speech-language pathology screening documented signs of swallowing impairment and the need for a mechanically altered diet. Despite these identified needs, record review showed that the resident’s care plan contained only two focus areas: pressure ulcer risk and antibiotic therapy, initiated in December. The care plan did not address dysphagia, aspiration risk, supervision during meals, respiratory issues, or treatments related to pneumonia, nor did it reflect her textured diet orders, aspiration precautions, or additional antibiotic treatment following hospitalization for pneumonia and subsequent readmission. Physician orders documented a low-concentrated sweets/no added salt diet with ground texture and thin liquids, and nephrology notes documented a hospitalization for right lower lobe pneumonia with antibiotic treatment and an ordered textured diet, but these changes and risks were not incorporated into the care plan. Interviews with the RNC, DON, and the MDS nurse revealed that the MDS nurse was responsible for initial care plan development and updates, and that acute care plans were expected to be completed immediately upon readmission with new conditions or concerns. The RNC and DON stated that the resident had not been continuously in the facility for 21 days to trigger a comprehensive care plan and that during the relevant period there was no MDS nurse for about a month, resulting in a backlog despite some corporate assistance. The MDS nurse described the expected process for post-hospital discharge review, including morning meetings to capture changes such as hospitalizations, diet changes, therapy referrals, and emerging risks, and confirmed that repeat hospitalizations, pneumonia, swallowing risks, diet downgrades, antibiotic use, and decline should be reflected in the care plan. The facility’s written policy required a comprehensive, person-centered care plan with measurable objectives and timetables for each resident and mandated IDT review and updates with significant changes in condition and upon readmission, but these requirements were not met for this resident.
Failure to Address Dental and Oral Health Needs in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's identified needs, specifically omitting dental and oral health care. A cognitively intact female resident with a history of depressive disorder, anxiety, diabetes, and heart disease required assistance with oral hygiene and was undergoing a multi-step denture process. Dental records indicated the resident was edentulous with gingival inflammation and required new dentures, with specific instructions from the dentist for staff to assist with oral hygiene and denture care. Despite these documented needs and instructions, the resident's care plan did not include any goals or interventions related to dental or oral health. The resident reported ongoing issues with her dentures, including poor fit, discomfort, and inability to wear them, which affected her ability to eat and speak. She also experienced a broken tooth, which she attributed to not being able to wear her dentures, and reported this to both the social worker and nursing staff, but no follow-up or adjustments were made. Interviews with facility staff revealed a lack of awareness regarding the resident's dental issues and the absence of dental care planning. The LVN stated she would typically notify the social worker and physician if dental problems were reported, but was unaware of any issues for this resident. The CNA was not aware the resident wore dentures, and the Regional Director of Clinical Services acknowledged the omission of dental needs in the care plan. The facility's own policy required care plans to include measurable objectives and be updated with changes in condition, but this was not followed for the resident's dental and oral health needs.
Failure to Provide Routine and Emergency Dental Services Due to Missed Appointments and Incomplete Paperwork
Penalty
Summary
The facility failed to provide or obtain routine and 24-hour emergency dental services for a resident who had a broken tooth and oversized dentures. The resident, who was cognitively intact but had mild memory/recall difficulties, had a history of depressive disorder, anxiety, diabetes, and heart disease. She required only set-up or clean-up assistance for oral hygiene. Dental records showed that she received new dentures, but subsequent scheduled follow-up and annual dental appointments were missed, with documentation indicating she was unavailable for treatment on two occasions. No further attempts or appointments were documented for several months. The resident reported ongoing issues with her dentures, stating they did not fit, looked unnatural, and made it difficult to eat and talk, leading her to stop wearing them. She also reported breaking a tooth while eating, which she attributed to not being able to wear her dentures. She communicated these concerns to the Social Worker and her nurse, but no adjustments, repairs, or replacements were offered, and she had not seen the dentist since receiving the dentures. Staff interviews revealed a lack of awareness or follow-up regarding her dental issues, with the Social Worker and Medical Records Custodian both acknowledging the resident's requests but unable to explain the lack of action or missed appointments. Further investigation revealed that the contracted dental provider had placed a 'do not treat' status on the resident's account due to incomplete re-enrollment paperwork, specifically a missing physician-signed form. The dental company representative stated that all necessary forms were sent to the Social Worker, but the required documentation was not returned, preventing the resident from receiving dental services. The Social Worker was unaware of the missing paperwork until the day of the survey and stated that forms were sent to her at different times, which may have contributed to the oversight. The facility's policy required Social Services to assist with dental appointments and maintain complete records, but these procedures were not followed in this case.
Failure to Provide Timely Catheter Care and Notification
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, a cognitively intact female with multiple diagnoses including neurogenic bladder and a history of UTIs, experienced increased pain and discomfort from her catheter. The facility did not adhere to physician orders for catheter care, as the resident's catheter was not changed on the scheduled dates, and there was a lack of documentation regarding catheter changes. The resident reported experiencing pain and discomfort from her catheter, with sediment observed in the catheter tubing and changes in urine color. Despite the resident's complaints of pain and discomfort, the nurse did not notify the nurse practitioner (NP) until two days later. The nurse admitted to not documenting the catheter change due to unfamiliarity with the new electronic medical records system and acknowledged the delay in notifying the NP about the resident's change in condition. Interviews with facility staff, including the Director of Nursing (DON) and the NP, revealed inconsistencies in catheter care and communication. The DON believed that the nurse's delay in notifying the NP was appropriate, while the NP expected to be informed of the resident's pain sooner. The facility's policy on catheter care emphasized the importance of documentation and physician notification for any condition changes, which was not followed in this case.
Improper Food Storage and Handling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was noted that the facility's refrigerator contained an open bin of raw chicken and an open bag of ham, both exposed to air, which is against proper food storage practices. Additionally, a prep table in the kitchen had boxes of bananas with visible spoilage, including black spots and a bug on one box, and fuzzy white spots on another. These observations indicate a lack of proper food storage and handling, which could potentially lead to food contamination. The Dietary Supervisor acknowledged these issues during an interview, stating that she conducted daily walkthroughs of the kitchen and was responsible for ensuring proper food storage by the dietary staff. She admitted that the chicken and ham should have been sealed and the spoiled bananas discarded. The facility's policy on food storage, which aligns with the FDA Food Code, emphasizes the importance of storing food in a manner that prevents contamination. However, the observed practices in the kitchen did not meet these standards, posing a risk of food-borne illness to residents.
Failure to Conduct PASRR Level 2 Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a mental illness diagnosis received the appropriate Pre-Admission Screening and Resident Review (PASRR) level 2 evaluation. The resident, a female with severe cognitive impairment, was diagnosed with schizophrenia, major depressive disorder, psychotic disturbance, mood disturbance, and anxiety. Despite these diagnoses, her PASRR level 1 screening incorrectly indicated that she did not have a serious mental illness, and no PASRR level 2 evaluation was conducted. This oversight was discovered during a review of the resident's records, which showed discrepancies between her documented mental health conditions and the PASRR level 1 screening results. Interviews with facility staff revealed a lack of awareness and understanding regarding the resident's PASRR status. The Administrator was unaware of the negative PASRR level 1 screening, and the MDS nurse incorrectly believed that the resident's diagnosis of dementia would preclude her from needing a PASRR level 2 evaluation. The MDS nurse also noted that the system listed schizophrenia as the primary diagnosis, but intended to change it to dementia. The facility's policy requires that any disagreements with PASRR findings be documented in the resident's medical record, and necessary services be provided or obtained from external resources, but this was not adhered to in this case.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident with a feeding tube received appropriate treatment and services to prevent complications. Specifically, LVN A did not verify the placement of the G-tube by aspirating stomach contents before administering water flushes and medications. Instead, LVN A used a syringe plunger to push water into the G-tube, contrary to the facility's protocol, which requires checking tube placement and gastric contents before medication administration. This oversight was observed during a medication administration session for a resident who was non-verbal and had severe cognitive impairment, as indicated by a BIMS score of 0. The resident, who was dependent on enteral feeding due to dysphagia, had a care plan that required checking for tube placement and gastric contents per facility protocol. However, LVN A admitted to forgetting to check for residuals before administering medications, which could lead to aspiration. The Director of Nursing (DON) was initially unaware of the specific policy requirements but later confirmed that staff should follow the facility's policy on G-tube medication administration. The facility's policy, updated in March 2019, mandates checking the feeding tube for placement and gastric content for residual feeding before administering medications.
Infection Control Breach Due to PPE Non-Compliance
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of LVN C during the assessment of a resident's foley catheter. The resident, a cognitively intact female with a BIMS score of 15, had been admitted for surgical aftercare and had multiple diagnoses, including a urinary tract infection and unspecified kidney failure. The resident was on enhanced barrier precautions, as indicated by physician orders and signage outside her room. Despite this, LVN C entered the room without donning the required personal protective equipment (PPE), which included a gown and gloves, as per the facility's enhanced barrier policy. During the observation, LVN C washed her hands and put on gloves but failed to wear a gown while assessing the foley catheter. This included touching the catheter tubing and repositioning the catheter bag, actions that required full PPE under the facility's policy. In an interview, LVN C acknowledged awareness of the enhanced barrier precautions and admitted to not following the protocol. The Director of Nursing confirmed that all staff had been trained on these precautions and emphasized the risk of infection spread due to non-compliance. The facility's policy clearly outlined the need for PPE during high-contact resident care, which was not adhered to in this instance.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement baseline care plans for two residents within 48 hours of their admission, as required by professional standards of care. Resident #118, a female with a displaced trimalleolar fracture of the right lower leg, was readmitted to the facility following hospitalization for surgery. Her baseline care plan was not completed until two days after her readmission. Similarly, Resident #141, a female with a displaced fracture of the greater trochanter of the right femur and chronic obstructive pulmonary disease, had her baseline care plan completed several days after her admission. Interviews with facility staff revealed a lack of awareness regarding the timeframe for completing baseline care plans. RN B, responsible for monitoring the completion of these plans, was unsure of the required timeframe and relied on the facility's electronic medical charting system for notifications. The Director of Nursing acknowledged the requirement for completion within 48 hours and suggested a possible error in the notification system. Despite these lapses, both staff members believed that the delay did not pose a risk to resident care, as staff communication ensured proper care delivery.
Incomplete Clinical Records for Psychotropic Medications
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who was prescribed psychotropic medications without documented diagnoses for which the medication was prescribed. The resident, a female with severe cognitive impairment, was receiving medications such as Fluoxetine, Gabapentin, Haloperidol, Memantine, Rivastigmine, and others for various conditions including depression, schizophrenia, and anxiety. However, the clinical records did not accurately reflect the diagnoses corresponding to the prescribed medications, particularly for Haloperidol, which was listed for agitation but was not the correct diagnosis according to the Director of Nursing (DON). During an interview, the DON acknowledged that the resident required both prescriptions of Haloperidol due to her diagnosis and behaviors, and that attempts at gradual dose reductions had failed, resulting in hostility. The DON stated that the resident was stable with her current medication regimen and did not recommend any changes. The resident herself denied having any mental health diagnoses and expressed reluctance to engage in conversation with the surveyor. This lack of accurate documentation placed the resident at risk of medical errors and a decline in health.
Failure to Obtain Proper Consent for Insurance Information
Penalty
Summary
The facility failed to uphold the resident's rights to dignity and self-determination by not ensuring proper consent was obtained from a resident with severe cognitive impairment. The resident, who was diagnosed with conditions including non-Alzheimer's dementia and had a BIMs score indicating severe cognitive impairment, was reported to have given verbal consent to receive information from a facility-affiliated insurance company. However, interviews revealed that the resident's responsible parties were not aware of this consent, and the resident herself appeared confused when questioned about it. Further investigation uncovered that a staff member, LBSW, had falsely documented verbal consents on patient choice forms without actually obtaining them from the residents. LBSW admitted to signing the forms herself and selecting verbal consent due to pressure from the previous administrator and corporate to increase referrals to affiliated companies. This unauthorized release of resident information violated the facility's policy on resident rights, which prohibits the unauthorized disclosure of resident information.
Deficiency in Wheelchair Cleanliness
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, specifically concerning the cleanliness of wheelchairs used by two residents. Observations revealed that one resident's wheelchair had a significant buildup of dust, debris, and a dried white substance on various parts of the chair, indicating it had not been cleaned for some time. The resident was unable to recall when the chair was last cleaned. Another resident's wheelchair was observed with a dried beige substance and spattered streaks on the wheel, suggesting inadequate cleaning practices. Interviews with staff, including the Director of Nursing (DON), Registered Nurse (RN), Licensed Vocational Nurse (LVN), Maintenance Director, and Certified Nursing Assistant (CNA), revealed inconsistencies in the cleaning procedures and responsibilities. While the DON stated that wheelchairs were cleaned regularly and that staff were responsible for monitoring and cleaning them, there was no set schedule for deep cleaning. The maintenance log showed only one entry for a wheelchair cleaning request, unrelated to the residents in question, indicating a lack of formal documentation and follow-up on cleaning needs.
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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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Nursing homes near Frisco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Victoria Gardens Of Frisco | 5.5 mi | ★★★★★ | 2 | 0 |
| Stonemere Rehabilitation Center | 6.6 mi | ★★★★★ | 3 | 0 |
| Baybrooke Village Care And Rehab Center | 6.8 mi | ★★★★★ | 20 | 0 |
| The Legacy At Willow Bend | 6.9 mi | ★★★★★ | 4 | 0 |
| Mustang Park Therapy And Living Center | 7.9 mi | ★★★★★ | 21 | 0 |
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