Prairie Village Healthcare Ctr
Inspection Findings
F-Tag F0687
F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
insects in webspace between 4th and 5th toes also seen by nurse, so nurse was cleaning both feet The facility's Charting and Documentation policy, revised 8/2006 documents all services provided to the resident, or any changes in the resident's medical condition shall be documented in the resident's medical record. All observations must be documented in the resident's medical record. All changes in resident's condition must be recorded which includes the date and time, name and title of who provided the care and
the assessment data and/or any unusual findings obtained during the treatment, notification of physician if indicated.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairie Village Healthcare Ctr
1024 West Walnut Jacksonville, IL 62650
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview the facility failed to maintain a complete and accurate medical record for 1 (Resident R2) of 3 sampled residents in review of complete and accurate medical records. Findings include: Resident R2's Undated Face Sheet, documents she was admitted to the facility on [DATE REDACTED]. No diagnosis of wounds or bugs on Resident R2's skin, including maggots. Resident R2's Minimum Data Set (MDS) dated [DATE REDACTED] documents she is alert. On 10/24/2025 at 3:33 PM V5, LPN stated V13, Facility Podiatrist entered the facility early in the morning on 10/20/2025 and assessed residents, including Resident R2. Resident R2's Electronic Medical Record (EMR) dated 10/23/2025 no documentation of V13's progress notes. On 10/23/2025 at 2:20 PM V1, Administrator stated V13, Facility Podiatrist doesn't share/send his progress notes with the facility, and he never has. On 10/24/2025 at 11:54 V13, Resident R2's Podiatrist stated he is the facility podiatrist, and sees over 25 plus patients at the facility approximately four times a year. V13 stated his office sends the facility his progress notes within 2-3 days
after he assesses the residents so his progress notes should be uploaded in the residents' medical records system. V13 stated he wasn't aware the facility wasn't receiving his progress notes or that his office wasn't forwarding his progress notes to the facility. The Facility's Charting and Documentation Policy, revised 8/2006 documents all observations and services performed must be documented in the resident's clinical record.
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PRAIRIE VILLAGE HEALTHCARE CTR in JACKSONVILLE, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in JACKSONVILLE, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PRAIRIE VILLAGE HEALTHCARE CTR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.