Prairie Village Healthcare CTR

In the surveyor’s words

From the most serious findings on record at Prairie Village Healthcare CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF690Apr 23, 2026

  A. Based on interview and record review the facility failed to obtain a urine sample timely and properly insert a catheter for 1 of 5 residents (R13) reviewed for urinary tract infections in the sample of 27. This failure resulted in the untimely collection of a urine specimen, with collection not occurring until 4 days after the order was received. During this time R13 suffered increasing symptoms with ultimately a malposition foley catheter being inserted into R13's urethra with a partially inflated balloon, despite the order given being for a straight catheter. […]

• Actual harm, isolatedF686May 15, 2025

  Based on interview, observation, and record review, the facility failed to identify and prevent a pressure ulcer for 1 of 7 (R37) reviewed for pressure ulcers in the sample of 29. This failure resulted in R37 developing a pressure ulcer on the left heel while at the facility. Findings Include: On 5/13/25 at 8:50 AM, R37 stated he has a pressure ulcer on his left heel. R37 stated he did not know it was there and a nurse found it. R37 stated he was concerned because he lost his right leg due to a pressure ulcer on his foot that never healed, and they had to amputate his leg. R37 was questioned if the dressing is changed every day, R37 stated no it is not. On 5/13/25 at 12:53 PM, V8, Wound Nurse Practitioner, was at the nurses' station with the wound treatment cart. V8 is wearing gloves. […]

• Actual harm, isolatedF689Jun 16, 2022

  Based on observation, interview and record review, the facility failed to provide supervision to prevent falls, investigate falls thoroughly to determine a root cause analysis and implement progressive interventions to prevent falls, provide safe transfers, and ensure transfer equipment is in good condition for 5 of 8 residents (R9, R10, R14, R17, R27) reviewed for falls and transfers in the sample of 31. This failure resulted in R17 falling 5 times,sustaining bumps to the back of her head, and another fall resulting in R17 going to the emergency room and receiving 8 staples to the back of her head. […]

• No harm, potential for more than minimal, widespreadF812May 15, 2026

  Based on observation, interview and record review the facility failed to ensure food is stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 52 residents living in the facility. Findings include: On 5/12/2026 at 2;54 PM, during the tour in the kitchen the ice machine in the kitchen had no air gap present. The white drainage hose from the ice machine went directly into a pump with no air gap present. This allows for potential backflow into the ice machine from the sewage drain. There is no air gap between the hose and the drain.On 5/12/2026 at 2:55 PM, V13, Dietary Manager stated she was not sure why there was no air gap. […]

• No harm, potential for more than minimal, widespreadF727May 15, 2025

  Based on observation, interview and record review the facility failed to provide a full time Director of Nursing (DON) and to provide a Registered Nurse (RN) 8 hours a day seven days a week. This failure has the potential to affect all 46 residents at the facility. Findings include: On 05/12/25 at 01:23 PM V1, Administrator stated she has not had a DON for 6 weeks. V1 stated the facility had advertised on different platforms and a DON is to start employment on 5/15/2025. The facility staffing schedule dated 4/28/2025-5/15/2025 documents 8 days out of 17 days the facility failed to provide RN coverage 8 hours a day on 4/30, 5/2, 5/8, 5/10, 5/11/, 5/13, 5/14, and 5/15/2025. On 5/13/2025, 5/14/2025 and 5/15/2025 a RN was not observed on duty at the facility. […]