Prairieview Lutheran Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Nov 5, 2025

  Based on interview, and record review the facility failed to assess, monitor for appropriate mode of mechanical lift of four residents reviewed for injury and transfer in a sample list of ten. This failure caused delay of treatment for R1's arterial bleed which required multiple transfusions and emergency surgical repair which eventually led to R1's death.The Immediate Jeopardy began on [DATE] when R1 fell and was not adequately assessed for injury or appropriateness of initiation of sit-to-stand lift. V1, Administrator was notified of the Immediate Jeopardy on [DATE] at 2:27PM. […]

• Actual harm, isolatedF689Dec 2, 2025

  Based on Observation, Interview and Record Review the facility failed to properly install foot pedals (R58), identify oxygen tubing and call light cord as trip hazards resulting in a fall (R1) and properly transfer R1 following a fall. These failures affect two of six residents (R1, R58) reviewed for accidents in the sample list of 29. These failures resulted in R58's left leg fracture and R1's right hip and right arm fracture. Findings include: The facility's Fall and Fall Risk Management policy documents that staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling. […]

• Actual harm, isolatedF689Jun 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure resident safety by not placing foot pedals on a resident's wheelchair while propelling the resident. This failure resulted in R1 experiencing a fall from the wheelchair, facial lacerations to the forehead, eye, and nose requiring eleven sutures to close. The facility also failed to implement fall prevention interventions according to R1's care plan. R1 is one of three residents reviewed for accidents on a sample list of eight. Findings include: 1. R1's Census Detail dated 6/10/25 documents R1 was admitted to the facility 1/19/17. […]

• Actual harm, isolatedF689May 14, 2025

  Based on interview and record review, the facility failed to identify an electric lift chair as a fall hazard, develop and implement post fall interventions, and thoroughly investigate falls for one of three (R1) reviewed for falls in the sample list of three. This failure resulted in R1 falling and sustaining a left femoral neck fracture requiring surgical repair. Findings include: R1's Minimum Data Set, dated dated dated [DATE] documents R1 had severe cognitive impairment and required substantial/maximal assistance from staff when moving from sitting to standing, for chair/bed transfers, and when walking. R1's Fall Risk assessment dated [DATE] documents R1 was at high risk for falling. […]

• Actual harm, isolatedF689Apr 26, 2024

  Based on interview and record review, the facility failed to provide safe and effective supervision of R1 during a transfer to prevent a traumatic fall. This failure resulted in R1 falling from a mechanical lift to the floor resulting in a hip fracture requiring emergency medical treatment and surgical repair at the hospital. R1 is one of four residents reviewed for accidents in the sample of four. Findings include: R1's medical diagnosis list (4/25/2024) documents R1's diagnoses include: Muscle Weakness, Paraplegia, History of Cerebral Infarction (partial brain tissue death due to disruption in blood flow), Osteoarthritis, Presence of Artificial Knee Joint, Apraxia (neurological disorder causing difficulty with skilled movements even when a person has the ability and desire to do them),… […]