Prairie View Senior Living

Inspectors wroteBased on observation, interview, and document review, the facility failed to facility failed to maintain surveillance of staff illness for preventing, monitoring and investigating illnesses to control infections for 1 of 1 infection control program. This had the potential to affect all 41 residents. The facility also failed to appropriately clean, rinse, and air-dry nebulizer apparatuses (mask, cup) after medication administration for 3 of 3 residents (R9, R14 and R21) and ensure 3 of 3 observed stand lifts, located in the 200 and 300 wing were appropriately cleaned between resident use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 resident's (R36) room was maintained in a homelike manner and ensure preventative maintenance was provided to repair numerous chips and scratches in the pain on 2 of 4 walls.

Inspectors wroteBased on interview and document review, the facility failed to have documented communication between the facility and hospice per their written agreement and ensure hospice notes were included in the medical record for 1 of 1 sampled hospice resident (R5).

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 8 sampled staff (director of nursing (DON) and nursing assistant (NA)-C) had initial or annual Alzheimer's and dementia training.

Inspectors wroteBased on interview and record review the facility failed to notify physician of skin alteration for 1 of 3 (R1) residents reviewed for change of condition.

Inspectors wroteBased on interview and document review, the facility failed to implement thier facility assessment to ensure 1 of 1 licensed practical nurse (LPN)-A and potentially 8 other licensed nurses (registered nurses (RN's) and LPN's) who administered insulin had yearly competencies for safe administration of insulin, and identifcation of complications of low or high blood sugar levels and any actions needed. This had the potential to affect all residents who were diabetic.

Inspectors wroteBased on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 43 residents. Review of the facilities QAPI minutes from June of 2024 through March of 2025 identified the following: 1. June 2024 minutes identified the facility chose a PIP of pain. The minutes did not include any data collection, analysis, evaluation of the identified concern, or an action plan. 2. July, August, September, October, November, December of 2024 and January, February, March of 2025 QAPI minutes identified the facility chose a PIP of pain but lacked any data collection, analysis or evaluation of the identified concern or an action plan. [...]

Inspectors wroteBased on interview and document review, the facility failed to notify the Office of the Ombudsman of transfers and discharge for 2 of 5 residents (R29 and R39) reviewed for hospitalizations and/or discharges.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 2 of 12 sampled residents (R13 and R14).

Inspectors wroteBased on interview and document review the facility failed to ensure 1 of 1 resident (R15) rapid acting insulin injection was administered according to the manufactures instructions.

Inspectors wroteBased on observation and interview the facility failed to ensure only authorized personnel entered 1 of 1 medication storage room.

Inspectors wroteBased on observation and interview the facility failed to ensure 1 of 1 nursing assistant (NA-A) entering the food preparation area in the kitchen wore a hair net.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 medication room was not used for resident insulin administration and/or blood glucose checks, in order to prevent potential cross-contamination. Observation and interview on 4/16/25 at 8:24 a.m. of licensed practical nurse (LPN)-A wheeled R8 into the medication storage room adjacent to the dining room. LPN-A donned gloves and primed Humulin Kwik pen with 2 units. LPN-A identified R8's blood sugar was 171 and then dialed up 20 units of insulin for administration. LPN-A administered the insulin in R8's left abdomen and discarded the insulin needle in the sharp's container and removed her gloves. LPN-A then wheeled R8 back out to the dining room table. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day for 3 of 12 days reviewed. This had the potential to affect all 44 residents.

Inspectors wroteBased on observation, interview and document review, the facility failed follow manufacturer's safety instructions for safe transfers for 1 of 2 residents (R4) who was not transferred with the appropriate mechanical lift sling.

Inspectors wroteBased on interview and document review, the facility failed to ensure 3 of 5 residents (R6, R10, and R11) were appropriately vaccinated against pneumonia and offered updated vaccinations and/or additional vaccinations when identified or upon admission. Furthermore, the facility failed to have a method or system to ensure the facility offered or provided any initial or updated vaccines to residents per Centers for Disease Control (CDC) vaccination recommendations.

Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of misappropriation of a resident's money was reported to the State Agency (SA) in a timely manner for 1 of 2 residents (R11) reviewed.

Inspectors wroteR17's admission Minimum Data Set (MDS) dated [DATE], identified her cognition was moderately impaired and had a diagnosis of dementia, anxiety, and depression. Review of 12/19/23, report to the State Agency (SA) identified R17 stated she was missing $100.00 that her son left her in her top drawer. The facility spoke to family members (FM)-E and FM-D, who identified FM-E had brought $100.00 in twenty-dollar bills to the facility. When he had returned a week later, the money was gone. FM-E reported he assumed staff had placed it in the facility safe and did not report it missing. The administrator searched the facility safe and the money was not there. With permission from R17 the administrator searched her room. While searching the room, R17 reported she thought her husband had taken the money home with him. The facility was unable to reach the husband for interview. [...]

Inspectors wroteBased on document review and interview, the facility failed to ensure 1 of 1 required member (infection preventionist) and/or their designee attended the quarterly Quality Assurance Performance Improvement (QAPI) meetings.