Prairie View Skilled Nursing

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ice machine drain line maintained a required air gap (empty space that ensures dirty sewer water cannot flow backward into the ice machine and contaminate the ice) to prevent potential contamination. This deficient practice had the potential to affect all residents who consumed ice from the facility ice machine. The facility census was 45. Review of the facility's policy titled, Ice Machine and Ice Storage Chests, revised January 2012, showed:- Ice machines and ice storage/distribution will be used and maintained to assure a safe and sanitary supply of ice;- Ice-making machines, ice storage chests/containers, and ice can all become contaminated by:a. unsanitary manipulation by employees, residents, and visitors;b. waterborne microorganisms naturally occurring in the water source;c. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess and investigate a choking incident that required the Heimlich maneuver (a procedure used to clear a blocked airway in a choking person) and failed to determine whether additional interventions were necessary to reduce a foreseeable risk of recurrent choking for one resident (Resident #2) out of one sampled resident. Following a choking incident that resulted in airway obstruction and required emergency intervention, the facility failed to investigate the cause of the incident, assess the resident's continued choking risk, evaluate the effectiveness of existing interventions, or determine whether revisions to the resident's care plan, diet, supervision, or other interventions were necessary to reduce the risk of recurrence. The facility census was 45. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an order for a catheter (a flexible tube inserted into the bladder to drain urine) and catheter care for one resident (Resident #13) out of three sampled residents. The facility census is 45. Review of the facility's policy titled, Catheter Care, Urinary, revised August 2022, showed: - The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections;- Did not address the need for catheter and catheter care orders. 1. Review of Resident #13's medical record showed:- admission date of 11/26/25;- Diagnosis of reflex neuropathic bladder (the blader does not empty properly due to a neurological condition); [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written copy of the notice of transfer or discharge to the resident and/or the resident's responsible party for three residents (Residents #14, #37, and #48) out of six sampled residents. The facility census was 46. Review of the facility's policy titled, Transfer or Discharge, Facility-Initiated, dated October 2022, showed: - Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy; - The resident and representative are notified in writing of the specific need for transfer or discharge; - Notice of transfer is provided to the resident/representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and the family or legal representative of their bed-hold policy at the time of the transfer to the hospital for three residents (Residents #35, #37, and #48) out of six sampled residents. The facility census was 46. Review of the facility's policy titled, Transfer or Discharge, Facility-Initiated, dated October 2022, showed: - Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy; - The resident and representative are notified in writing of the notice of the facility bed-hold and policies; [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Resident #35) with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of one sampled resident. The facility's census was 46. Review of the facility's policy titled, Behavioral Health Services, dated February 2019, showed: - The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practical physical, mental, or psychosocial well-being in accordance with comprehensive assessment and plan of care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for two out of two sampled medication carts. The facility also failed to implement procedures to ensure medications were accurately administered, documented, disposed of, and reconciled for one resident (Resident #12) outside of the 12 sampled residents This practice had the potential to affect all residents. The facility census was 46. Review of the facility's policy titled, Controlled Substances, last revised November 2022, showed: - Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 28 opportunities with three errors made, resulting in an error rate of 10.71% for one resident (Resident #27) out of four sampled residents. The facility's census was 46. Review of the facility's policy titled, Insulin Administration, last revised September 2014, showed: - Three key characteristics of insulin are: onset of action - how quickly the insulin reaches the bloodstream and begins to lower blood glucose, peak effects - the time when the insulin is at its maximum effectiveness, and duration of effect - the length of time during which the insulin is effective; - Rapid-acting insulin - onset of 10-15 minutes (min), peak of 0.5-3 hours (hrs.), duration of 3-6 hrs.; - Regular/short-acting insulin - onset of 0.5-1 hr., peak of 2.5-5 hrs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one resident (Residents #27) out of one sampled resident was free from significant medication errors when staff did not check blood sugars prior to administering insulin (a medication that regulates blood sugar levels). The facility's census was 46. Review of the facility's policy titled, Insulin Administration, last revised September 2014, showed: - Three key characteristics of insulin are: onset of action - how quickly the insulin reaches the bloodstream and begins to lower blood glucose, peak effects - the time when the insulin is at its maximum effectiveness, and duration of effect - the length of time during which the insulin is effective; - Rapid-acting insulin - onset of 10-15 minutes (min), peak of 0.5-3 hours (hrs.), duration of 3-6 hrs.; [...]

Inspectors wroteBased on observation, interview, and record record review, the facility failed to employ a qualified director of food and nutrition services. The facility did not have a Dietary Manager (DM) with a background or required years of experience in food preparation, food service and/or food storage. This deficient practice had the potential to affect all residents in the facility. The facility census was 46. Review of the facility's policy titled, Dietician, dated November 2022, showed: - If a qualified dietitian is not employed full-time (35 or more hours per week), a director of food and nutrition services will be designated. The individual will: a. Be a certified dietary manager, or; b. Be a certified food service manager, or; c. Be nationally certified for food service management and safety, or; d. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician's order for one resident (Resident #11) outside the sample. The facility failed to follow wound care orders for one resident (Resident #17) out of two sampled residents and failed to follow physician orders for Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) to evaluate and treat as indicated for two residents (Resident #26 and #30) out of four sampled residents. The facility census was 34. Review of the facility's policy titled, Physician's Services, revised February 2021, showed: - The medical care of of each resident is supervised by a licensed physician; - Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease in their ROM for one resident (Resident #8) out of two sampled residents. The facility census was 34. Review of the facility's policy titled, Restorative Nursing Services, revised July 2017 showed: - Residents will receive restorative nursing care as needed to help promote optimal safety and independence; - Restorative nursing consist of nursing interventions that may or may not be accompanied by formalized rehabilitative services; - Residents may be started on a restorative nursing program upon admission and during the course of the stay; - Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure placement of the Foley catheter (a tube inserted into the bladder to drain urine) tubing and drainage bags for one resident (Resident #27) out of four sampled residents. The facility census was 34. Review of the facility's policy titled, Urinary Catheter Care, revised August 2022, showed the position of the drainage bag should be lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 1. Review of Resident #27's medial record showed: - An admission date of 01/31/24; - Diagnosis of urinary retention (an inability to empty the bladder of urine); - Physician Order Sheet (POS), dated April 2024, with an order to change the Foley catheter monthly, dated 02/22/24. Observations of the resident showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 35 opportunities with three errors made, resulting in an error rate of 8.57% for three residents (Residents #1, #5 and #22) out of three sampled residents. The facility's census was 34. Review of the facility's policy titled, Administering Medications, dated April 2019, showed: - Medications are administered in accordance with prescriber orders, including any required time frame; - The policy did not address insulin pen administration technique. Review of the Humalog/lispro (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Kwik Pen (Insulin in a pen-type device) instructions, revised, July 2023, showed: - Pull the Kwik Pen cap straight off; - Wipe the rubber seal with an alcohol swab; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This had the potential to affect all residents. The facility census was 34. Review of the facility's policy titled, Medication Labeling and Storage, dated February 2023, showed: - If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items; - Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of the facility's policy titled, Administering Medications, dated April 2019, showed: - The expiration/beyond use date on the medication label is checked prior to administering; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper infection control practices during the medication administration for one resident (Resident #5) out of four sampled residents. The facility failed to maintain proper infection control practices during incontinent care for one resident (Resident #8) out of four sampled residents. The facility failed to maintain proper infection control practices during a wound care treatment for one resident (Resident #17) out of two sampled residents. The facility also failed to maintain proper infection control practices during blood glucose monitoring when the staff did not properly disinfect the glucose monitor three residents (Resident #1, #22, and #30) out of three sampled residents. The facility census was 34. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised October 2023, showed: [...]