Prairie Vista Village

In the surveyor’s words

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

• Actual harm, isolatedF686Oct 14, 2021

  Based on observation, staff, resident interviews, and clinical record review the facility failed to prevent the development of a pressure wound for 1 of 1 resident reviewed (Resident # 14). The resident required extensive assistance of 1 staff for dressing. When staff donned the resident's shoes and failed to adjust them properly in the back, this caused the back of the shoe to rub and apply pressure and friction on the skin over the resident's Achille's tendon and heel bone. On 8/7/21, staff identified and documented a Stage II pressure ulcer to the resident's left heel that measured 2.5 centimeters (cm) by 1 cm by 0.3 cm. By 10/11/2021, the area had increased slough and drainage and had developed into a Stage 3 pressure sore. The facility reported a census of 33 residents. […]

• No harm, potential for more than minimal, widespreadF812May 16, 2024

  Based on observation, staff interview, and policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 39. Findings include: 1. Observation of the kitchen on 05/13/24 at 10:01 AM revealed the refrigerator contained the following items; a bag of open to the air, unsealed, undated ham slices sitting in a pool of what appeared to be its own juices. A container of whipping cream that was open to the air, with no label to indicate when it had been opened. A Sealed, unlabeled, undated bag of an unknown food product. […]

• No harm, potential for more than minimal, patternF812May 22, 2025

  Based on observations, policy review, and staff interview the facility failed to serve food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness during one of one meals observed. Facility staff also failed to cover facial hair (beard) while preparing food. The facility reported a census of 43 residents. Findings include: Observations revealed the following: a. On 5/19/25 at 10 AM, Staff A, [NAME] was in the kitchen shredding pork for the lunch meal, Staff A had facial hair of full beard without any coverage of the beard. b. On 5/21/25 at 11:15 AM, Staff B, [NAME] was in the kitchen preparing food for the lunch meal. Staff B had facial hair of beard without any coverage of the beard. c. […]

• No harm, potential for more than minimal, isolatedF552May 27, 2026

  Based on clinical record reviews staff interview, and facility policy review, the facility failed to ensure that 1 out of 5 residents reviewed (Resident #36) for medications were provided with information, education regarding the risks and benefits of psychotropic medications or choice of alternatives and options. The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment of Resident #36, dated 5/3/26 documented diagnoses that included: Non-Alzheimer's dementia and mood disorder. The MDS coded Resident #36 took high-risk medications included, antipsychotic, antianxiety and antidepressants. The MDS recorded a Brief Interview for Mental Status (BIMS) score of 11, indicated moderate cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF578May 27, 2026

  Based on interviews, observation, clinical record review, and Iowa Physician Orders for Scope of Treatment, (I-POST) documents the facility failed to ensure consistency with process's to ensure clear direction with Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR) code status for 3 of 16 reviewed for Advance Directives (Resident #4, #36, #40) . The facility reported a census of 45 residents. Findings include:1.Resident #4 I-POST documented, Do Not Resuscitate (DNR) signed Resident #4 and by the medical provider with signature date [DATE]. Resident #4 Electronic Record Profile and Order Summary documented Code Status, CPR/Attempt resuscitation. 2.Resident #36 I-POST documented, DNR with signature date of [DATE]. […]