Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure timely assessment and implementation of
preventative measures to prevent the development of a pressure ulcer for one (R1) of three residents
reviewed for pressure ulcers. This failure resulted in R1 developing a facility-acquired Stage 3 pressure
ulcer to the coccyx.Findings include: R1 is a [AGE] year-old resident admitted to the facility on [DATE] to
11/13/25 with diagnoses including but not limited to: atrial fibrillation, seizure, hypertension,
cerebrovascular accident, obesity, depression, cognitive and communication deficit, dementia, cerebral
amyloid angiopathy, anxiety, history of encephalopathy, and coronary artery disease. R1's (MDS) Minimal
Data Set assessment of 10/13/2025, section C, the BIMS (Brief Interviewed Mental Status) score was
03/15 (severely impaired cognition). MDS of 10/13/2025, GG section R1 is dependent on self-care- Helper
does all the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or
more helpers is required for the resident to complete the activity. R1 is dependent on mobility assistance
and requires roll left and right, sit to lying tub/shower transfer: The ability to get in and out of a tub/shower.
R1 requires helper does all of the effort. The resident does none of the effort to complete the activity. Or the
assistance of 2 or more helpers is required for the resident to complete the activity. On 2/7/2025 at 1:45
PM, V4 (Wound Care Nurse) said, (R1) had no wound impairment on admission and stage 2 on the coccyx
area was noted on 10/31/2025. We have shower sheets and skin alteration sheets for the nursing assistants
to fill out when they observe any skin impairment. The floor nurse will notify the physician and obtain orders
if I am not in the building. I will add the resident to the wound physician for the weekly rounds and do the
treatment for the residents when I am in the building. The nurses are expected to do treatment if I am not in
the building. The surveyor requested shower sheets, skin impairment sheets, and nursing routine skin
assessment but V4 said, the facility does not keep shower sheets or skin impairment sheets past a month
per facility policy. V4 said, I assessed (R1) on 10/31/2025, called the physician, and added the air mattress,
dietary supplements, and added (R1) to the list of the wound physician rounds. R1's physician's order dated
10/03/2025 reads in part, Skin assessment weekly on shower or bath day. Per record review: 10/3/25:
admission, intact skin10/3-10/31: no documented weekly assessments10/31/25: Stage 2 identified11/11/25:
Stage 3 documentedRecord review of 11/11/2025 V5 (Wound Care Physician) progress notes noted a
stage 3 pressure ulcer to the sacrum measuring 4 x 5.5 x 0.1 cm with light sero-sanguinous drainage and
fair healing potential and estimated time to heal 4 - 6 Months. On 2/7/2026 at 3:53 PM, V2 (Director of
Nursing) said, nurses are expected to complete the skin assessment, check the shower skin assessment,
and any skin impairment to be assessed, call the physician, and obtain orders. V2 stated, We have a wound
care nurse who will complete the assessment and treatment. I cannot put a timeframe on when a wound
will develop and turn into stage 2. I expected the nurses to turn, reposition, and keep residents dry and
clean, and monitor the skin. Also, we take into consideration nutrition and
Residents Affected - Few
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145927
Printed: 05/15/2026
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
145927
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/08/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairie Oasis
16000 South Wabash
South Holland, IL 60473
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 0686
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
keep residents hydrated. The surveyor requested skin assessments, shower sheets, and only received the
skin assessment from admission on [DATE] and 10/31/2025, when R1 already had a stage 2 pressure ulcer
to the coccyx area. V2 said the facility does not keep records of showers past the current month or the
entire last month. V2 and V3 (Director of Clinical Service) both reviewed records for routine skin
assessment under the electronic medical records with the surveyor, but none were found. V3 said skin
assessments are expected to be added under the MAR (Medication Administration Records) for the nurses
to complete. When questioned about how frequently V3 said per standard of care, on admission, and
weekly for 4 weeks. During the records review with V2 and V3 of the MAR, no skin assessments were found
as per the physician's order. Care plan and interventions updated on 10/31/2025 reads, skin will be
checked during routine care on a daily basis, and during the weekly and biweekly bath or shower schedule.
No additional assessments were provided by the facility at the time of this survey. In the absence of
documentation, the facility failed to demonstrate that required skin assessments were completed or that the
pressure ulcer was unavoidable in accordance with professional standards of practice and facility policy. On
2/7/2026 at 4:47 PM, V1(Administrator) provided the facility policy titled Pressure Injury and Skin Condition
Assessment Policy dated 9/2016, reads:Purpose:To establish guidelines for assessing, monitoring, and
documenting the presence of skin breakdown, pressure ulcers, assuring interventions are
implemented.Standards:2-Residents identified by the Braden scale of being at high risk of skin breakdown
will have a weekly skin assessment x4 by a licensed nurse.4-Each resident will be observed for skin
breakdown daily during care on assigned bath day by the CNA (Certified Nursing Assistant). Changes shall
be promptly reported to the charge nurse, who will perform the initial assessment.Wound Care Skin
Inspection TableBath twice weekly or as necessary. Avoid hot water; use a mild cleansing agent that
minimizes irritation and dryness of the skin. During the cleaning process, care should be taken to minimize
the force and friction applied to the skin.Documentation of weekly head-to-toe assessment by the licensed
nurse in the resident's chart or on the facility-approved form.Daily head-to-toe skin assessment by
caregivers.
Event ID:
Facility ID:
145927
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
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
145927
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/08/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairie Oasis
16000 South Wabash
South Holland, IL 60473
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 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
interview and record review, the facility failed to maintain complete and accurate clinical records by not
retaining skin assessment and skin monitoring documentation necessary to demonstrate compliance with
physician orders as part of the resident's medical record. This failure applied to one (R1) of three residents
reviewed for medical records. Findings include: R1 was admitted to the facility on [DATE]. A physician's
order dated 10/03/2025 required weekly skin assessments on shower or bath day.Facility policy titled
Pressure Injury and Skin Condition Assessment Policy dated 9/2016 required:Weekly head-to-toe skin
assessments by a licensed nurse for residents at high risk;Daily observation for skin breakdown by certified
nursing assistants;Documentation of skin assessments in the resident's medical record or on
facility-approved forms.On 2/7/2026 at 1:45 PM, V4 (Wound Care Nurse) stated the facility utilized shower
sheets and skin alteration sheets completed by nursing assistants to document skin observations. When
requested to provide these records for R1, V4 stated the facility does not retain shower sheets or skin
alteration sheets beyond one month per facility policy.On 2/7/2026 at 3:53 PM, V2 (Director of Nursing)
confirmed the facility does not keep shower or skin assessment documentation beyond the current or
previous month. V2 stated nurses are expected to complete skin assessments and monitor skin condition;
however, when requested, the facility was only able to produce skin assessments dated 10/03/2025
(admission) and 10/31/2025 (after skin breakdown was identified).During record review conducted with V2
(Director of Nursing) and V3 (Director of Clinical Services), the surveyor was unable to locate
documentation of routine weekly or daily skin assessments in the electronic medical record. V3 stated skin
assessments were expected to be documented on the Medication Administration Record (MAR); however,
review of the MAR revealed no documented skin assessments as required by physician order or facility
policy.As a result, the facility failed to maintain complete, accurate, and retrievable clinical records
necessary to demonstrate that required skin assessments and monitoring were performed. The facility's
failure to retain clinical documentation prevented verification of compliance with physician orders, facility
policy, and professional standards of practice.
Event ID:
Facility ID:
145927
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the February 8, 2026 survey of PRAIRIE OASIS?
This was a inspection survey of PRAIRIE OASIS on February 8, 2026. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PRAIRIE OASIS on February 8, 2026?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.