Prairieview Lutheran Home

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to properly install foot pedals (R58), identify oxygen tubing and call light cord as trip hazards resulting in a fall (R1) and properly transfer R1 following a fall. These failures affect two of six residents (R1, R58) reviewed for accidents in the sample list of 29. These failures resulted in R58's left leg fracture and R1's right hip and right arm fracture.

Inspectors wroteBased on interview and record review the facility failed to report low blood glucose levels to the physician for one of one resident (R49) reviewed for physician notification in the sample list of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a homelike environment by failing to repair a damaged wall for one of one resident (R2) reviewed for homelike environment in the sample list of 29.

Inspectors wroteBased on interview and record review the facility failed to report an injury of unknown origin for one resident (R51) of one resident reviewed for abuse in a sample list of 29Findings Include:R51's Care Plan revised 9/23/25 lists the following diagnoses: Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. This Care Plan also documents (R51) is on anticoagulant therapy (Eliquis) Related to Atrial Fibrillation and history of Deep Venous Thrombus. R51's Minimum Data Set (MDS) dated [DATE] documents R51 is severely cognitively impaired. R1's progress note dated 9/13/25 at 12:43PM documents large bruise was noticed to Rt. arm and hand of (R1). Bruise approximately 20cm x 7cm to Rt. antecubital area, and 18cm x 8cm to Rt. distal anterior area of arm and hand. Wound care nurse notified. Waiting for orders. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a physician ordered nutritional supplement for one of four residents (R1) reviewed for nutrition in the sample list of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to change nebulizer equipment for one of three residents (R61) reviewed for respiratory care in the sample list of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure hand hygiene was performed prior to insulin administration for two of 12 residents (R9, R49) reviewed for medication administration in the sample list of 29.

Inspectors wroteBased on interview, and record review the facility failed to assess, monitor for appropriate mode of mechanical lift of four residents reviewed for injury and transfer in a sample list of ten. This failure caused delay of treatment for R1's arterial bleed which required multiple transfusions and emergency surgical repair which eventually led to R1's death. The Immediate Jeopardy began on [DATE] when R1 fell and was not adequately assessed for injury or appropriateness of initiation of sit-to-stand lift. V1, Administrator was notified of the Immediate Jeopardy on [DATE] at 2:27PM. The surveyor confirmed by observation, record review, interview that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on interview and record review the facility failed to ensure all staff were trained on the facility's Quality Assurance Performance Improvement Program. This failure affects all 84 residents in the facility. The facility's Facility assessment dated as reviewed 9/26/25 includes staff education/training upon hire and annually through (web-based training and education system), new employee orientation, and in-services. This Facility Assessment does not include QAPI training as one of the topics that staff will be trained on. On 11/4/25 at 10:55 AM, employee education and training were reviewed with V48 Human Resources and V48 was asked about QAPI training. V48 confirmed there was no documentation of QAPI training in the (web-based training and education system) or as part of the facility's new employee orientation training. [...]

Inspectors wroteBased on interview and record review the facility failed to have the physician document and sign progress notes for each visit for five of six residents (R1, R2, R5, R9, R10) reviewed for physician visits in the sample list of 10. 1.) R1's undated Face Sheet documents R1's primary physician as V25. R1's Progress Notes, recorded by V10 Licensed Practical Nurse, document V25 evaluated R1 on 6/27/25, 8/22/25 and 9/9/25. As of 11/3/25, R1's electronic medical record (EMR) did not include any Physician Progress Notes by V25. 2.) R2's undated Face Sheet documents R2's primary physician as V25. R2's Progress Notes, recorded by V10, document V25 evaluated R2 on 6/27/25, 8/22/25, and 10/24/25. As of 11/3/25, R2's EMR did not include any Physician Progress Notes by V25. 3.) R5's undated Face Sheet documents R5's primary physician as V25. [...]

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an injury of unknown origin for one of four residents (R1) reviewed for accidents in the sample list of 10.

Inspectors wroteBased on interview and record review the facility failed to safely transfer a resident (R7) resulting in a fall and failed to investigate this fall for one of four residents (R7) reviewed for accidents in the sample list of 10. On 10/27/25 at 10:14 AM, R7 stated R7 had a recent fall while trying to get into bed with staff assistance. R7 stated a gait belt was not used during this transfer. R7's Minimum Data Set, dated [DATE] documents R7 as cognitively intact, R7 requires partial/moderate staff assistance for chair/bed transfers, and R7 had two or more falls without injury since the prior assessment. R7's Care Plan dated 8/26/24 documents R7 is at risk for falls, R7 has a transfer restorative program due to weakness and R7 transfers with one assist, gait belt, and grab bar or walker. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident safety by not placing foot pedals on a resident's wheelchair while propelling the resident. This failure resulted in R1 experiencing a fall from the wheelchair, facial lacerations to the forehead, eye, and nose requiring eleven sutures to close. The facility also failed to implement fall prevention interventions according to R1's care plan. R1 is one of three residents reviewed for accidents on a sample list of eight.

Inspectors wroteBased on interview and record review, the facility failed to identify an electric lift chair as a fall hazard, develop and implement post fall interventions, and thoroughly investigate falls for one of three (R1) reviewed for falls in the sample list of three. This failure resulted in R1 falling and sustaining a left femoral neck fracture requiring surgical repair.

Inspectors wroteBased on interview and record review the facility failed to accurately complete a Minimum Data Set (MDS) Assessment for one of three (R2) residents reviewed for falls in the sample list of three.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's right to privacy for three of three residents (R1, R2, R3) reviewed for resident rights on the sample of three. Findings Include: The Resident's Rights for People in Long Term Care Facilities dated May 2018 documents residents have the right to privacy. The facility may not give information about residents or their care to any unauthorized person without the resident's permission. 1. R1's Medical Diagnoses list dated February 2025 documents R1 is diagnosed with Alzheimer's Disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and requires staff assistance for all Activities of Daily Living. 2. R2's Medical Diagnoses list dated February 2025 documents R2 is diagnosed with Alzheimer's Disease. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate pain management was available, by failing repeatedly to schedule a pain clinic appointment for a medication pump refill. This failure affected one of two residents (R1) reviewed for pain on the sample list of 27. Findings Include: On 11/12/24 at 12:15 pm, R1 was seated in a motorized wheelchair, bedside. R1 stated R1 has a pain pump in her abdomen that has not been filled in months. R1 said R1 is reliant on this pain pump to stop the burning in her feet. R1 stated, I have pain pills but they don't work to relieve the burning pain in feet. My doctor retired and the facility has done nothing to help me find a new doctor to provide refills (surgically implanted pain pump medications). I was going out to my doctor about every six weeks. [...]

Inspectors wrote2. R25's Physician Progress Notes dated effective date 8/23/24, 9/27/24, and 10/25/24, all document R25's temperature, pulse, respirations, blood pressure, oxygen saturation, and weights, all having a November 2024 date. There are no current vital assessments documented for the actual vitals that were completed on the actual assessment dates of 8/23/24, 9/27/24, and 10/25/24. On 11/15/24 at 10:32 AM, V11 Administrator stated the Physician Progress Notes dated effective dates are the dates the actual assessment was completed by the physician (V27), and the vital sign information is not correct for the dates of the completed assessments. Based on record review and interview the facility repeatedly failed to follow their policy to maintain complete and accurate medical records for two (R1, R25) of 18 residents reviewed for medical records on the sample list of 27.

Inspectors wroteBased on interview and record review, the facility failed to accurately obtain weights, obtain daily weights as ordered, and report significant weight changes to appropriate staff for one resident (R25) of one resident reviewed for weight loss in the sample list of 27.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from abuse by failing to prevent misappropriation of a resident's narcotic pain medication. This failure affected one of three residents (R4) reviewed for abuse in the sample of six. Findings Include: The Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy dated 12/23/21 documents the term Abuse can includes misappropriation of resident property. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The Incident Report for incident of 7/12/24 documents R4 had an order for Hydrocodone (Opioid) to be taken every 6 hours. On 7/12/24, V9 Registered Nurse contacted Hospice to attempt to refill the Hydrocodone. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately maintain narcotic administration records for one of three residents (R4) reviewed for narcotic medication use on the sample of six. Findings Include: The facility's Controlled Substances policy dated 6/11/21 documents controlled substances (narcotic medications) are reconciled upon receipt, administration, disposition, and at the end of each shift. The nurse administering the medication is responsible for recording the time of administration, method of administration, quantity of the medication remaining, and signature of nurse administering the medication. R4's Physician Order Sheet dated July 2024 documents R4 is diagnosed Alzheimer's Disease, Dementia, Behavioral Disturbance, Mood Disturbance, Anxiety, Seizures, Major Depressive Disorder, Heart Disease, and Muscle Weakness. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide safe and effective supervision of R1 during a transfer to prevent a traumatic fall. This failure resulted in R1 falling from a mechanical lift to the floor resulting in a hip fracture requiring emergency medical treatment and surgical repair at the hospital. R1 is one of four residents reviewed for accidents in the sample of four.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that dignity was maintained, by failing to respond to a call light in a timely manner. This failure resulted in a delay in meeting toileting needs for a dependent resident and prevented a residents right to participate in a scheduled activity. This failure affected one of 21 residents (R11) reviewed for dignity on the sample list of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to use proper sequence anterior then posterior technique, perform hand hygiene, remove soiled gloves, and prevent cross contamination during perineal care for a resident with a Urinary Tract Infection (UTI). This failure affected one of four residents ( R11) reviewed for a UTI on the sample list of 21.