Prairie Crossing LVG & Rehab

In the surveyor’s words

From the most serious findings on record at Prairie Crossing LVG & Rehab, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 3, 2024

  Based on observation, interview, and record review the facility failed to have interventions in place to prevent resident to resident abuse. This applies to 3 of 3 residents (R1, R2, R3) reviewed for abuse in the sample of 3. This failure resulted in R1 being sent to the hospital, receiving a hematoma, and experiencing pain with activities of daily living. The findings include. R2's Admission Record (Face Sheet) showed an original admitted [DATE] with diagnoses to include dementia with behavioral disturbances, depression, and anxiety. R2's 3/15/24 Admission Minimum Data Set (MDS) showed he had severe cognitive impairment with a brief interview for mental status (BIMS) score of 3 out of 15. […]

• Actual harm, isolatedF689Dec 6, 2023

  Based on observation, interview, and record review the facility failed to ensure a resident was transferred and ambulated in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 3. These failures resulted in R1 sustaining a fractured nasal bone, sutures to the forehead, and bruising. The findings include: R1's face sheet printed on 12/6/23 showed diagnoses including but not limited to Alzheimer's disease, dementia with agitation, anxiety disorder, wandering, impulsiveness, difficulty walking, muscle weakness, and abnormalities of gait and mobility. R1's facility assessment dated [DATE] showed severe cognitive impairment. The assessment showed substantial/maximal staff assistance needed for transferring from sitting to standing. […]

• Actual harm, isolatedF686Sep 15, 2023

  Based on observation, interview, and record review the facility failed to cleanse a stage four pressure ulcer in a manner to prevent cross contamination and failed to ensure staff were knowledgeable in the use of a pressure reduction device for 1 of 2 residents (R42) reviewed for pressure in the sample of 14. These failures resulted in R42 being at an increased risk of infection and delayed wound healing. The findings include: R42's face sheet printed on 9/13/23 showed diagnoses including but not limited to Alzheimer's disease, chronic obstructive pulmonary disease, diabetes mellitus, protein-calorie malnutrition, chronic kidney disease, neuromuscular bladder, and stage 4 pressure ulcer of the sacral region (lower back/upper buttock area). […]

• Actual harm, isolatedF689Sep 15, 2023

  Based on observation, interview and record review, the facility failed to supervise a resident at high risk for falls, with previous falls in the facility, and failed to supervise a resident with wandering behaviors for 2 of 8 residents (R41, R26) reviewed for safety and supervision in the sample of 14. This failure resulted in R41 falling, sustaining a hip fracture, and being sent out to a local hospital for evaluation and surgical treatment. The findings include: 1. R41's Admission Record, printed by the facility on 9/13/23, showed she had diagnoses including vascular dementia, severe, with behavioral disturbance, a history of falling, unsteadiness on feet, and abnormalities of gait and mobility. […]

• Actual harm, isolatedF690Sep 15, 2023

  Based on observation, interview, and record review the facility failed to ensure catheter changes were performed as ordered and failed to ensure catheter care orders were in place for 2 of 3 residents (R6, R20) reviewed for catheters in the sample of 14. This failure resulted in catheters having a gray discoloration for residents with recurrent urinary tract infections (R6, R20), R6's urine was cloudy yellow with sediment, and R20's urine was thick, foul-smelling, and amber in color. The findings include: 1. On 9/14/23 at 10:05 AM, V10 and V11 (Certified Nursing Assistants - CNAs) transferred R6 to bed from the wheelchair. V10 and V11 laid R6 on her back and removed her pants and incontinence brief. R6 had an indwelling catheter inserted. The catheter was attached to a leg bag. […]