Prairie View Senior Living

In the surveyor’s words

From the most serious findings on record at Prairie View Senior Living, in the surveyor’s own words.

• Immediate jeopardy, patternF744Jul 26, 2021

  Based on observation, interview, and document review, the facility failed to appropriately assess, monitor, and intervene when 1 of 1 resident (R1) with known increasing physical behaviors caused by dementia, physically abused 5 of 35 residents (R2, R3, R5, R6 and 1 unknown resident) resulting in skin tears, a lacerated lip, and 2 puncture wounds caused by biting. R1 was also at risk for abuse when 1 of 1 resident (R4) threatened to harm R1 with his oxygen tank. This resulted in an immediate jeopardy (IJ). The IJ began on 5/9/21, when R1 had physically assaulted R3 by grabbing R3's arm and pinching her and the facility failed to assess R1's dementia and behaviors and develop interventions to manage behaviors and prevent further resident to resident altercations. […]

• Immediate jeopardy, isolatedF684Feb 9, 2023

  Based on interview and document review, the facility failed to identify and act upon an emergent change of condition (COC) for 1 of 1 resident (R36) who had significant changes in her health. The facilities failure to get immediate emergent medical evaluation resulted in delayed treatment for severe sepsis (life threatening infection) resulting in serious harm. R36 died that afternoon in the hospital as a result of her infection. The IJ began on [DATE], when the facility failed to appropriately identify and intervene when an emergent COC occurred for R36 whose health had dramatically declined. […]

• No harm, potential for more than minimal, widespreadF880May 20, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF838Apr 16, 2025

  Based 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. Finding include: R15's 1/21/25, Significant Change Minimum Data Set (MDS) assessment identified R15 cognition was intact, he had no pain, no behaviors, was on a therapeutic diet, received insulin, anticoagulant, diuretic, hypoglycemic medication daily and was on isolation. […]

• No harm, potential for more than minimal, widespreadF867Apr 16, 2025

  Based 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. […]