Prairieview at the Garlands

In the surveyor’s words

From the most serious findings on record at Prairieview at the Garlands, in the surveyor’s own words.

• Actual harm, isolatedF686May 7, 2026

  Based on observations, interviews, and record review, the facility failed to thoroughly assess, identify, treat, monitor, and implement adequate interventions to prevent the development and/or worsening of pressure ulcers for one of one (R7) resident reviewed for pressure ulcers. This failure resulted in R7 developing an unstageable pressure ulcer on the left heel, an open skin impairment to the sacral area, and a reddened area to the right upper, inner thigh.Findings include:R7 is an [AGE] year-old resident admitted to the facility on [DATE] with diagnoses, in part but not limited to heart disease, peripheral vascular disease, congestive heart failure, and cerebral infarction. […]

• Actual harm, isolatedF760Apr 10, 2024

  Based on interview and record review the facility failed to transcribe a resident's admission medication orders in a manner to prevent a significant medication error. This failure resulted in R1 developing hypotension (low blood pressure) and dizziness after receiving eight (8) doses of a diuretic medication (water-pill), one pill per day, from [DATE]-[DATE], instead of PRN (as needed), as shown per R1's hospital discharge orders. This failure applies to 1 of 6 residents (R1) reviewed for medication administration and significant medication errors in the sample of 6. The findings include: A facility incident report dated [DATE] showed R1 was admitted to the facility on [DATE], from a local hospital. The report showed R1 began complaining of dizziness on [DATE]. […]

• Actual harm, isolatedF760Jan 4, 2023

  Based on interview and record review the facility failed to ensure two residents (R1, R2) received the correct dosages of physician prescribed medication. This failure resulted in R1 receiving 17 additional doses of an anti-depressant medication which contributed to R1 being hospitalized for a mental status change. This applies to 2 of 4 residents (R1, R2) reviewed for medication errors in the sample of 4. The findings include: 1.) R1's nursing progress notes show she was admitted to the skilled unit of the facility on 11/17/22. Her face sheet shows she had diagnoses including: major depression, anxiety, and a history of falls. R1's nursing progress note for 12/11/22 at 6:15 PM, shows R1 was having increased confusion and poor balance and gait. […]

• No harm, potential for more than minimal, widespreadF761Feb 19, 2025

  Based on observation, interview, and record review the facility failed to have a properly functioning lock for the drawer containing the residents' emergency supply of controlled substances. This failure has the potential to affect all residents in the facility. The findings include: On 2/18/25 at 10:45 AM, during medication room inspection, the drawer containing the emergency supply of controlled substances was opened without a key. The lock was not functioning as intended. On 2/18/25 at 10:45 AM, V3 Registered Nurse stated, I have not checked or accessed this drawer in a long time. […]

• No harm, potential for more than minimal, widespreadF880May 24, 2023

  Based on observation interview, interview, and record review the facility failed to ensure enhanced barrier precautions were implemented and failed to change gloves and perform hand hygiene during incontinence care in a manner to prevent cross contamination. This has the potential to affect all 15 residents residing in the facility. The findings include: 1. The facility's Resident Census and Condition Report (CMS 672) dated May 22, 2023, shows a resident census of 15. On May 23,2023 at 09:16 AM, V2 Director of Nursing (DON) said the facility has no residents on transmission based precautions (TBP) or enhanced barrier precautions (EBP). V2 said there is no specific facility policy on enhanced barrier precautions. […]