Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Azria Health Prairie Ridge during CMS and state inspections, most recent first.
A resident with multiple medical conditions and moderate cognitive impairment, seated near the nurses’ station while on the phone, swung his arm back and struck another resident with severe dementia twice in the upper back as she self-propelled her wheelchair past him, following her usual routine. Staff reported that this resident could become irritable when redirected, and he then stood up and hit and pinched a CNA who intervened. The aggressor’s care plan identified mood and behavior issues and directed staff to anticipate needs, provide positive interaction, and intervene to protect others’ safety, while the other resident’s care plan addressed impaired cognition and the need for supervision and consistent routine. The facility’s abuse policy states residents must be protected from abuse by anyone, including other residents.
A resident with multiple chronic conditions, moderate cognitive impairment, and dependence on staff for mobility allowed a CNA to use her EBT food stamp card to buy snacks for her and also to purchase items for the CNA, without specifying a spending limit. The CNA used the card at a grocery store to buy a large volume of items, and later could not clearly recall what she had purchased for herself. When the receipt was reviewed, the resident identified numerous items she had not requested that were believed to be for the CNA, totaling a substantial amount. Other staff reported they understood from dependent adult abuse training that using a resident’s resources or accepting gifts was wrong, and facility policy explicitly prohibited exploitation and misappropriation of resident property, yet the resident’s EBT benefits were used inappropriately by staff.
Two residents were issued emergency discharges following repeated altercations, with the facility failing to adequately address their needs or properly notify and involve their guardians and families in the process. Both residents were transferred to hospitals for psychiatric evaluation, found not to require admission, and were subsequently refused readmission by the facility, resulting in one resident remaining hospitalized and the other returning to independent living with limited support.
Surveyors identified multiple instances where staff failed to store raw meat on the bottom shelf, handled food with gloved hands without changing gloves between tasks, and left an ice scoop handle in contact with ice. Staff interviews confirmed awareness of proper procedures, but these were not consistently followed, resulting in unsanitary food storage and handling.
Three residents experienced a lack of dignity and respect due to staff actions, including inappropriate verbal and physical cues during feeding, use of personal phones during care, and inadequate supply of properly sized incontinence briefs. These actions were confirmed by resident and staff interviews, observations, and review of facility policies, highlighting failures to follow care plans and maintain resident dignity.
A resident with multiple chronic conditions experienced significant weight loss over several months. Although dietary staff documented the weight loss and implemented interventions, the facility failed to provide evidence that the physician was notified of these changes, as required by policy.
Care plans were not updated for two residents who experienced significant weight loss and for another resident who was no longer receiving dialysis, despite clear evidence of these changes. Staff interviews revealed lapses in responsibility for updating care plans, and the facility's policy requiring timely revisions after significant changes was not followed.
A resident with lower extremity impairment and intact cognition did not consistently receive restorative nursing interventions as recommended by therapy, due to inconsistent staff assignment and lack of dedicated restorative personnel. The care plan outlined specific exercises and activities, but staff interviews revealed that restorative programming was often missed or inadequately implemented when the responsible staff member was reassigned to other duties.
The facility did not ensure that its services met professional standards of quality, as observed through practices that did not align with established care guidelines.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
Three medication errors were observed among twenty-seven opportunities, resulting in a medication error rate of 11.11%. Errors included a resident receiving insulin after eating instead of before meals, another resident receiving the wrong dosage form of Ferrous Sulfate, and a third resident being given a different formulation of Polyethylene Glycol than prescribed. These incidents occurred despite facility policies requiring medications to be administered as ordered and within specified time frames.
Multiple residents experienced significant medication errors involving anticoagulants, insulin, and narcotic pain medications due to failures in documentation, communication, and order transcription. In several cases, residents received double doses of medications or had medications administered at incorrect times, and one resident received an incorrect anticoagulant regimen due to a transcription error that was not clarified with the discharging hospital. These errors were identified through observation, interviews, and record review, and were not consistent with the facility's medication administration policy.
The facility failed to complete quarterly MDS assessments on time for several residents, with delays noted in the completion of assessments beyond the required 14-day period from the ARD. Interviews with staff, including the MDS Coordinator and DON, confirmed these delays, and the facility's policy did not address quarterly MDS requirements.
The facility did not complete annual MDS assessments on time for two residents. One resident's assessment was still in process beyond the required timeframe, while another's was completed late. Staff interviews confirmed the delay, which was against the facility's policy requiring completion within 14 days of the ARD.
A facility failed to update a PASRR for a resident with new mental health diagnoses and medications. The resident had a history of anxiety, depression, and psychotic disorder, and was taking antipsychotic and antidepressant medications. Despite significant changes in diagnoses and medication orders, the PASRR was not resubmitted. The MDS coordinator misunderstood the criteria for significant changes, which was later clarified by the administrator. The facility's policy required a PASRR Level II evaluation for new or changed behaviors indicating a serious mental disorder, but this was not followed.
A facility failed to administer a pneumococcal vaccine to a resident who was eligible for the PCV 20 vaccine. The resident had previously received the Prevnar 13 vaccination and consent for the PCV 20 was obtained. However, due to a lack of communication and clarity among staff regarding responsibility for vaccinations, the vaccine was not administered. The DON relied on the Infection Preventionist, who was unaware of the need to offer the vaccine, resulting in a disconnect in the process.
The facility failed to maintain a clean and hazard-free environment, with observations of debris and trash under beds, cluttered hallways, and inconsistent cleaning practices. A resident reported that their room was not always cleaned thoroughly, contributing to the deficiency.
The facility failed to follow enhanced barrier precautions and hand hygiene practices. A resident on enhanced barrier precautions was assisted by CNAs without protective gowns. Another resident received care without staff sanitizing hands before providing a snack. Observations revealed empty sanitizer dispensers and staff not using them, violating the facility's hand hygiene policy.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse in the form of a resident-to-resident altercation. On the date of the incident, one resident was seated near the nurses’ station while using the phone, and another resident, who routinely self-propelled her wheelchair around the nurses’ station in the evenings, attempted to pass by. As the second resident tried to pass, the seated resident swung his arm back and struck her twice in the upper back. This event was witnessed by a restorative aide and a registered nurse, and was later documented in nursing progress notes and a facility-reported incident. The resident who initiated the altercation had multiple medical diagnoses, including cerebrovascular accident, hemiplegia, aphasia, adjustment disorder with depressed mood, a history of falls, and diabetes. His most recent MDS prior to the incident showed a BIMS score of 9/15, indicating moderate cognitive impairment, and documented that he was usually able to make himself understood and to understand others. His care plan identified mood and behavior issues, including verbal aggression and a tendency to not want to wear clothes, and directed staff to anticipate and meet his needs, assist with coping and interacting, provide positive interaction, discuss inappropriate behavior when reasonable, and intervene as necessary to protect the rights and safety of others by approaching calmly, redirecting, and removing him from situations as needed. The resident who was struck had diagnoses including non-Alzheimer’s dementia, cognitive communication deficit, and adjustment disorder with mixed anxiety and depressed mood, with a BIMS score of 6/15 indicating severe cognitive impairment. She was sometimes able to make herself understood and to understand others, and used a wheelchair as her primary mode of transport. Her care plan addressed impaired cognitive function and directed staff to ask yes/no questions, cue, reorient, supervise as needed, keep her routine consistent, and provide consistent caregivers. On the day of the incident, she was following her usual routine of self-propelling around the nurses’ station when she was hit. Staff interviews described that the striking resident could become irritable when redirected and that he hit the other resident before staff could intervene, then stood up and subsequently hit and pinched the CNA who attempted to stop him. The facility’s abuse prevention policy states that residents have the right to be free from abuse by anyone, including other residents, and that the facility will protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone.
Failure to Protect Resident From Financial Exploitation of EBT Food Benefits
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from financial exploitation by a staff member. The resident had multiple diagnoses including adult failure to thrive, type 2 diabetes with complications, alcoholic cirrhosis of the liver, anxiety, and depression, and had a BIMS score indicating moderate cognitive impairment, though she was always able to make herself understood and to understand others. She was totally dependent on staff for substantial assistance with repositioning, transfers, and was unable to stand or ambulate. Her care plan identified that she had difficulty coping with lifestyle changes, limitations in functional abilities, and the loss of her husband as caregiver, and that she needed assistance with problem solving and psychosocial support. The events leading to the deficiency began when the resident, who received monthly EBT food stamp benefits, asked a CNA to use her EBT card to purchase snacks for her and told the CNA she could also buy items for herself with the card. The resident did not specify an amount the CNA could spend, did not know exactly what the CNA purchased for herself, and recalled the total purchase being a little over $100. Some purchased items required refrigeration and were placed in a refrigerator outside the resident’s direct control, and the resident later reported she had lost track of those items. The resident stated she did not think she had done anything wrong and was unaware at the time that designated facility staff were available to shop for residents. Interviews and document review showed that the CNA acknowledged using the resident’s EBT card at a grocery store, spending a little over $100, and purchasing food for both the resident and herself, but could not clearly recall all items she bought for herself. A grocery store receipt showed 68 items purchased for a total of $268.93 with the resident’s EBT card. When the receipt was later reviewed with the resident, she identified several items totaling $115.96 that she stated she had not requested and believed were purchased for the CNA. Other staff, including another CNA/Restorative Aide, stated they knew it was wrong to use a resident’s resources or accept gifts from a resident based on dependent adult abuse education. The facility’s abuse, neglect, exploitation, and misappropriation prevention policy required protection of residents from exploitation and misappropriation of property, development of protocols to prevent and identify such incidents, and investigation of possible misappropriation, underscoring that the resident’s funds were wrongfully used by staff despite these policies.
Failure to Meet Resident Needs Prior to Emergency Discharge
Penalty
Summary
The facility failed to make adequate attempts to meet the needs of two residents prior to issuing emergency discharges following a series of resident-to-resident altercations. Both residents had intact cognitive status, as indicated by their BIMS scores, and required varying levels of assistance with activities of daily living. The clinical records showed a pattern of verbal disputes and threats of violence between the residents and their peers, with interventions primarily consisting of moving residents to different rooms and de-escalating situations. On the date of the final altercation, the facility obtained orders for emergency psychiatric evaluations and arranged for both residents to be transferred to local hospitals. The process of discharge was initiated while the residents were at the hospitals, with the facility citing the safety of individuals in the facility as the reason for the emergency discharges. The discharge forms included information about placement and appeal rights, but there were lapses in communication with the residents' guardians and family members. One resident's guardian was not informed about the appeals process and did not receive any forms to sign, while the other resident's family could not be reached prior to the discharge. Both residents were ultimately not admitted to the hospitals for psychiatric reasons, and the facility refused to readmit them upon the hospitals' requests. Interviews with facility staff revealed that the decision to discharge was made due to a perceived lack of available rooms to accommodate residents with behavioral issues. The staff also demonstrated a lack of awareness regarding the proper notification and involvement of guardians in the discharge process. As a result, one resident remained hospitalized while the other was taken to his apartment by family members, with concerns noted about his ability to manage medications and daily living needs.
Failure to Maintain Sanitary Food Storage and Handling Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and handling practices within the facility's kitchen. Raw hamburger was found thawing in a metal basin on an upper shelf above meal trays, and frozen chicken breasts were placed on a refrigerator shelf above containers of fruit, contrary to facility policy requiring raw meat to be stored on the bottom shelf to prevent cross-contamination. Staff interviews confirmed that staff were aware of the correct procedures but did not consistently follow them, with several staff acknowledging the improper placement of raw meat and the risk of contamination. During meal service, staff were seen using tongs to remove buns from packaging and then using their gloved hands to handle the buns and other items without changing gloves between tasks. Additionally, an ice scoop was repeatedly left in the ice container with the handle in contact with the ice, and staff continued to use the scoop without changing gloves after touching other surfaces. Staff interviews revealed knowledge of proper glove use and ice scoop handling, but these practices were not consistently implemented. The facility's policy requires measures to prevent cross-contamination, including proper storage of raw meat, adherence to hygiene and sanitary practices, and changing gloves between tasks, all of which were not followed during the observations.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
Staff failed to treat three residents with dignity, as evidenced by multiple interviews, observations, and record reviews. One resident with severe cognitive impairment and a history of stroke and aphasia was repeatedly told by staff to chew and swallow his food, despite care plan instructions to avoid such directives. Staff were observed and reported to have taken away the resident's plate, rubbed his cheek in an aggressive manner, and used a mean tone when instructing him to eat. The speech therapist and physical therapist both confirmed witnessing inappropriate staff interactions, including frustration and aggressive verbal and physical cues, which made the resident feel 'disgusting.' The Director of Nursing acknowledged that telling the resident to swallow was a trigger and that staff should not touch the resident's cheek or plate. Another resident with intact cognition reported that staff on the third shift used their personal phones during work hours, making the resident feel undervalued and uncomfortable asking for help. Multiple staff interviews confirmed that personal phone use occurred during shifts, including during resident care and in hallways. The facility's cell phone policy prohibits personal phone use during working hours and in patient care areas, except for authorized business purposes, but staff and social services confirmed that the policy was not consistently followed, leading to resident dissatisfaction and irritation. A third resident, also with intact cognition and total incontinence, reported that the facility frequently ran out of appropriately sized incontinence briefs, resulting in the resident having to wear briefs that were too large or of a different type. Staff confirmed that supply shortages led to residents wearing incorrect sizes, which caused discomfort and skin issues. The staffing coordinator and Director of Nursing acknowledged the supply issues, with staff sometimes borrowing briefs from other rooms and residents being left without the correct size until new supplies arrived. The facility's policy requires staff to be trained on resident dignity and respect, but these incidents demonstrate a failure to uphold those standards.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss for a resident on two separate occasions, as required by facility policy. The resident, who had intact cognition and multiple comorbidities including CHF, diabetes, COPD, morbid obesity, gout, hypothyroidism, and hyperlipidemia, experienced a weight loss of over 10% in six months and over 5% in one month. Documentation showed that the dietitian identified and documented the significant weight loss and made recommendations, including meal enrichment and weekly weights, and noted that faxes were sent to the clinician. However, the facility was unable to provide documentation that the physician was actually notified or made aware of the weight losses, despite multiple staff interviews and record reviews. The resident's care plan and dietary notes reflected ongoing monitoring and interventions for nutritional risk, including the use of supplements and meal enrichment strategies. The resident herself was aware of her weight loss and attributed it to poor appetite following her husband's death and a recent illness. Despite these interventions and awareness by dietary staff, there was no evidence in the medical record or from staff that the physician was notified of the significant changes in the resident's condition, as required by the facility's policy on change in condition.
Failure to Update Care Plans After Significant Changes in Resident Condition
Penalty
Summary
The facility failed to update care plans in a timely manner for three residents following significant changes in their conditions. One resident experienced a significant weight loss of over 10% in six months, as documented in the weight summary, but the care plan was not updated to reflect this change. Another resident, who was at nutritional risk due to multiple medical conditions and had severely impaired cognition, also experienced a weight loss of nearly 15% over five months, yet the care plan did not reflect this significant change. Staff interviews confirmed that the care plans for both residents should have been updated to address the significant weight loss, but this was not done, partly due to a recent change in dietician staffing and unclear responsibilities for updating care plans. Additionally, a third resident's care plan continued to indicate the need for dialysis, despite the resident no longer receiving dialysis services. The resident and staff interviews confirmed that the resident had not been on dialysis for some time, and the care plan had not been revised to reflect this change. The facility's policy requires care plans to be revised when there is a significant change in a resident's condition, but this was not followed in these cases.
Failure to Implement Restorative Nursing Program for Resident with Mobility Impairment
Penalty
Summary
A deficiency occurred when the facility failed to implement a restorative nursing program as recommended by therapy for a resident with impaired lower extremity mobility. The resident, who was cognitively intact and had no upper extremity impairment but did have lower extremity impairment, reported only participating in restorative exercises once. The care plan indicated a need for restorative programming to maintain functional mobility and prevent decline, with specific interventions outlined, including the use of a seated bike, sit-to-stand activities, and lower extremity strengthening and stretching exercises. Despite these documented interventions, staff interviews revealed inconsistent implementation of the restorative program. The staff member primarily responsible for restorative care was frequently reassigned to other duties, such as providing showers, and could not explain how restorative programming was completed when working on the floor. No other staff were officially assigned to restorative programming, and coverage was sporadic. The Restorative Nurse's involvement was limited to documentation assistance, and the Director of Nursing stated that nurses were expected to fill in if the primary staff was unavailable. The facility's policy allowed for restorative nursing care upon discharge from therapy, but the recommended program was not consistently followed.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines for care delivery. The report notes that the facility did not maintain the expected level of quality in the services rendered, as required by regulatory standards. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident’s medical history or condition at the time of the deficiency were not provided in the report.
Medication Error Rate Exceeds Regulatory Standard
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in an observed error rate of 11.11%. This was identified through observation, interview, and record review, where three medication errors were found among twenty-seven opportunities for three residents. One resident, with intact cognition and a history of insulin use, received insulin after already consuming food, contrary to the prescribed administration of insulin before meals. Another resident, also with intact cognition and a diagnosis of anemia, was administered a 324 mg enteric-coated tablet of Ferrous Sulfate instead of the prescribed 325 mg oral tablet. A third resident, with intact cognition and a prescription for Polyethylene Glycol 1450, was given Clearlax 3350 instead of the ordered medication. The facility's policies require medications to be administered as prescribed, within specified time frames, and in accordance with prescriber orders. However, staff failed to follow these protocols, as evidenced by the administration of medications at incorrect times, incorrect dosages, and substitution of medications. These actions directly contributed to the facility's elevated medication error rate, exceeding regulatory standards.
Significant Medication Errors Due to Documentation and Communication Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving the administration of anticoagulants, insulin, and narcotic pain medications. In one case, a resident with intact cognition and a physician order for Warfarin received a double dose due to a lack of communication and documentation between nursing staff and a medication aide during a shift change. The nurse administered the medication but did not document it, leading the medication aide to administer a second dose. This resulted in the resident receiving 8 mg instead of the prescribed 4 mg of Warfarin. Another incident involved a resident with diabetes who was prescribed sliding scale insulin. The LPN checked the resident's blood sugar and administered insulin after the resident had already eaten, contrary to the physician's order to administer insulin before meals. The blood sugar was recorded at 200 mg/dL, and 2 units of insulin were given, but the timing did not align with the prescribed protocol. A third resident, also with intact cognition, was prescribed oxycodone for chronic pain. Due to a similar breakdown in communication and documentation, both an LPN and a medication aide administered a 5 mg dose of oxycodone, resulting in the resident receiving a double dose. Additionally, a resident with severe pulmonary hypertension was prescribed Apixaban following hospital discharge, but a transcription error led to the incorrect entry of the medication order. The facility failed to clarify the discharge instructions with the hospital, resulting in the resident receiving an incorrect dosing regimen. These incidents were confirmed through interviews, record reviews, and direct observation, and were not in accordance with the facility's medication administration policy.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed in a timely manner for five residents out of nineteen reviewed. Specifically, the assessments for Residents #9, #18, #26, #29, and #34 were not completed within the required timeframe. For instance, Resident #18's assessment had an Assessment Reference Date (ARD) of 4/25/24, but the completion date was 5/20/24. Similarly, Resident #26's assessment with an ARD of 8/9/24 was still in process at the time of the review. Other residents also experienced delays in the completion of their assessments, with completion dates extending beyond the 14-day requirement from the ARD. Interviews with facility staff, including the MDS Coordinator, Director of Nursing (DON), and the Administrator, confirmed the delays in completing the MDS assessments. The MDS Coordinator acknowledged the lateness of the assessments for Residents #18 and #26. Both the DON and the Administrator expressed their expectations for timely completion of the MDS assessments. Additionally, the facility's Comprehensive Assessment Policy, dated December 2023, did not address the requirements for quarterly MDS assessments.
Delayed MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure timely completion of annual Minimum Data Set (MDS) assessments for two residents, as required by their policy. Resident #18's MDS assessment, with an assessment reference date (ARD) of July 25, 2024, was still in process at the time of the survey. Resident #26's MDS assessment, with an ARD of May 9, 2024, was completed on June 3, 2024, indicating a delay. Interviews with the MDS Coordinator, Director of Nursing (DON), and the Administrator confirmed the assessments were late and should have been completed within 14 days of the ARD. The facility's Comprehensive Assessments Policy mandates that annual assessments be completed at least every 366 days unless a significant change or correction assessment has been conducted since the last comprehensive assessment.
Failure to Update PASRR for Resident with New Diagnoses and Medications
Penalty
Summary
The facility failed to resubmit a PASRR (Preadmission Screening and Resident Review) for a resident with new mental health diagnoses and psychotropic medications added to their plan of care. The resident, who was reviewed for PASRR, had a history of anxiety disorder, depression, and psychotic disorder, and was taking antipsychotic and antidepressant medications. Despite these changes, the PASRR Level 1 Screen Outcome indicated no Level II was required unless a significant change occurred. However, the resident's care plan and medical records showed significant changes, including new diagnoses of major depressive disorder with psychotic symptoms and delusional disorders, as well as new medication orders for Depakote, Duloxetine, and Seroquel. The MDS coordinator, during an interview, acknowledged a misunderstanding regarding what constituted a significant change, believing it only applied to hospital admissions for mental issues. The administrator later clarified that changes in medications and medical diagnoses also required a new PASRR. The facility's policy stated that new onset or changes in behavior indicating a serious mental disorder should be referred for a PASRR Level II evaluation. Despite this policy, the necessary PASRR update for the resident was not completed, leading to the deficiency.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer a pneumococcal vaccine to Resident #8, who was eligible for the PCV 20 vaccine. The resident had previously received the Prevnar 13 vaccination in 2019 and was noted to be eligible for the PCV 20 as of February 13, 2024. The resident's immunization record was reviewed by the ARNP, and verbal consent for the vaccine was obtained from the resident's daughter, with education provided on the risks and benefits. However, the vaccine was not administered. Interviews with facility staff revealed a lack of clarity and communication regarding responsibility for administering the vaccine. The DON stated that he relied on the Infection Preventionist to manage vaccinations, but the ADON/IP was unaware of the need to offer the vaccine to Resident #8. The DON acknowledged the oversight and expressed an expectation for follow-through, but there was a disconnect in the process, resulting in the resident not receiving the vaccine. The facility's policy indicated that pneumococcal vaccines should be administered per CDC recommendations, but this was not followed in this instance.
Failure to Maintain Clean and Hazard-Free Environment
Penalty
Summary
The facility failed to maintain a clean and hazard-free environment for its residents, as evidenced by multiple observations of unclean conditions in resident rooms and cluttered hallways. On several occasions, debris such as rubber gloves and trash were found under the bed in a resident's room and remained there for multiple days despite housekeeping services being performed. Additionally, a gown and deodorant container were observed on the floor in another room, with the deodorant container remaining even after partial cleaning. Hallways were also noted to be cluttered with mechanical lifts, standing devices, and wheelchairs, posing potential hazards. Interviews with staff and residents further highlighted the deficiency in maintaining cleanliness. The Housekeeping and Laundry Supervisor stated that resident rooms are supposed to be cleaned daily, including sweeping, mopping, and sanitizing, with deep cleaning scheduled for one room per hall each day. However, a resident reported that their room was not consistently cleaned, with housekeeping often neglecting areas under or behind furniture. This inconsistency in cleaning practices contributed to the observed deficiencies in maintaining a safe and clean environment.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions and consistent hand hygiene practices, as observed during a survey. Resident #6, who has intact cognition and requires moderate assistance with daily activities, was on enhanced barrier precautions due to a catheter. However, during personal care, two CNAs, Staff E and Staff F, did not wear protective gowns as required. Both staff members acknowledged the oversight during interviews, with one stating she forgot to wear a gown. Additionally, Resident #5, who is severely cognitively impaired and dependent on staff for assistance, was observed receiving care without proper hand hygiene practices being followed. Staff G and Staff H assisted with transfers and incontinence care but did not sanitize hands before providing a snack to the resident. Furthermore, sanitizer dispensers were found empty, and staff were not observed using them. Other staff members, including a registered nurse and a CNA, were also seen assisting multiple residents without sanitizing their hands between contacts, contrary to the facility's hand hygiene policy.
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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 Mediapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wapello Specialty Care | 4.9 mi | — | 2 | 0 |
| New London Specialty Care | 13.6 mi | — | 6 | 0 |
| Southeast Iowa Regional Medical - Klein Center | 13.6 mi | — | 2 | 1 |
| Oakview Nursing And Rehabilitation | 14.3 mi | — | 0 | 0 |
| Sunrise Terrace Nursing & Rehabilitation Center | 16.9 mi | — | 0 | 0 |
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