Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Prairie View Senior Living during CMS and state inspections, most recent first.
The facility failed to track staff illness for infection control, and staff with vomiting and fever returned to work the next day despite state guidance referenced in the record. It also failed to properly clean, rinse, and air-dry nebulizer parts after use for three residents, and three stand lifts were observed with dirt and food-like debris on the pedals while waiting to be used. Policies in the record required surveillance of staff illness, cleaning of respiratory equipment after each use, and cleaning/disinfecting of multiple-use items such as mechanical lifts after each use.
Resident Room Not Maintained in Homelike Condition: A resident with HF, HTN, and arthritis had intact cognition and no behaviors, but her room had numerous chips and scratches in the paint on two walls behind her chair and beside her bed. The resident said the damage had been there since she moved in. The admin stated the MDS used a TELS system for work orders and tracking PM, but was unsure whether resident rooms were included in a PM schedule; RN-A was unaware of the damage, and QAPI and safety meeting records did not show specific PM checks for resident rooms.
A resident receiving hospice services had a terminal prognosis, dementia, anxiety disorder, and moderately impaired cognition, but the facility failed to document communication with hospice and failed to keep hospice notes in the medical record for multiple extended periods. Hospice staff reported routine visits and verbal report to facility staff, while the RN stated the facility did not document those communications despite the hospice contract requiring both parties to record each exchange.
Missing Required Alzheimer’s and Dementia Training for DON and NA-C: The facility failed to ensure the DON and an NA-C completed required initial or annual Alzheimer’s/dementia training. Record review showed both staff lacked training on Alzheimer’s disease and related disorders, ADL assistance, problem solving with challenging behaviors, and communication skills. The administrator acknowledged the missing training, while facility orientation materials and the facility assessment identified dementia care topics as part of staff training.
A resident developed significant skin changes, including a large fluid-filled blister and discoloration on the right foot, which were documented by nursing staff over several days without timely physician notification. The physician was only informed during routine rounds, contrary to facility policy requiring immediate notification of new skin alterations.
A facility failed to ensure that all licensed nurses administering insulin had completed annual competencies for safe insulin administration and recognition of blood sugar complications. A resident with diabetes and multiple comorbidities received rapid-acting insulin before a meal, resulting in severe hypoglycemia and hospitalization. Staff interviews revealed uncertainty about protocols, and documentation showed missing or outdated competency records.
The facility did not implement or document a Performance Improvement Project (PIP) for pain management as required by its QAPI program. Over several months, QAPI meeting minutes showed no evidence of data collection, analysis, evaluation, or an action plan for the chosen PIP, potentially affecting all residents.
Surveyors found that two residents' MDS assessments were not accurately completed: one resident's MDS failed to reflect a documented serious mental illness, and another resident's MDS did not indicate ongoing hospice care despite clear documentation in the medical record and care plan. Nursing staff confirmed these inaccuracies in the assessments.
A resident with diabetes and multiple comorbidities was given rapid-acting insulin significantly before receiving a meal, contrary to manufacturer instructions. The resident experienced severe hypoglycemia and required emergency care. Nursing staff did not follow standing orders for hypoglycemia management, and there were gaps in staff competency assessments and policy guidance regarding insulin administration.
An LPN brought a resident into the medication storage room to administer insulin, citing staffing constraints and the need for privacy. The practice of taking residents into the medication room was confirmed by the ADON, though the DON was unaware and expressed concerns about infection control and medication storage. Facility policy restricts access to the medication supply to authorized personnel only.
A nursing assistant entered the kitchen food-prep area without wearing a hair net while a cook was plating meals, despite facility protocol requiring hair restraints in this area. The NA believed nurse aides were exempt from this requirement, but both the dietary manager and DON confirmed that all staff must wear hair nets when entering the food-prep area.
An LPN administered insulin to a resident in the medication storage room, deviating from standard infection control practices. The LPN cited staffing shortages as the reason for using the medication room, and interviews revealed that this practice had occurred previously for privacy. The DON was unaware of this and recognized it as an infection control concern, as facility policy requires medication storage areas to be kept clean and restricts access to authorized personnel only.
The facility failed to have an RN on duty for 8 consecutive hours on three days, potentially affecting all 44 residents. On two days, RNs worked only a few hours, and on one day, no RN was present. The business office manager confirmed the lack of coverage, and the administrator mentioned a corporate policy allowing 4 free days per quarter without RN coverage, but no policy was provided.
A resident with severe cognitive impairment was transferred using an inappropriate sling, contrary to manufacturer's instructions. The resident's care plan lacked specific sling details, and staff used a Guldmann sling with a Volaro lift, unaware of its incompatibility. The facility had no specific policy for transfers, relying on staff competencies.
Infection Surveillance and Equipment Cleaning Failures
Penalty
Summary
The facility failed to maintain surveillance of staff illness for preventing, monitoring, and investigating illnesses to control infections. The infection preventionist stated she had not tracked staff illness since January 2025 and did not have a surveillance process in place for staff illnesses. The facility’s Attendance Slip form documented call-ins, lateness, no-shows, and early departures, but it did not include fields for symptom onset, symptom resolution, return-to-work status, or whether staff were cleared using national or state standards. Review of May 2026 attendance slips showed one nursing assistant called in with nausea and vomiting and returned to work the next day, and another called in with vomiting and fever and also returned to work the next day. The infection preventionist stated staff were allowed to return to work 24 hours after symptoms resolved and was unaware that staff should be out for 72 hours with symptoms of potential norovirus per state guidance. The facility also failed to appropriately clean, rinse, and air-dry nebulizer apparatuses after medication administration for three residents. During the initial tour, three residents’ nebulizers were observed lying on bedside tables or nightstands and had not been disconnected, rinsed, or air dried. Later, a registered nurse administered a nebulizer treatment to one resident and the apparatus was still intact from the morning administration; the nurse poured medication into the mask and medication cup and stated the apparatus should have been disassembled, cleaned, and rinsed after each nebulizer administration. Medication administration records showed that two of the residents had received nebulizer treatments earlier that day. The respiratory equipment cleaning policy stated that after each use, staff were to rinse the mouthpiece and medication cup with water and allow them to air dry. The facility further failed to ensure three stand lifts located on the 200 and 300 wings were appropriately cleaned between resident uses. Random observations throughout the day showed all three lifts sitting in the hall waiting to be used with dirt and food-like debris on the pedals. A registered nurse stated stand lifts were to be cleaned after each use. The nursing weekly cleaning task policy identified multiple-use items, such as a mechanical lift, were to be cleaned and disinfected after each use.
Resident Room Not Maintained in Homelike Condition
Penalty
Summary
The facility failed to ensure one resident's room was maintained in a homelike manner and failed to provide preventative maintenance to repair numerous chips and scratches in the paint on two of four walls. The resident's MDS identified a re-admission to the facility in November 2023 with diagnoses of heart failure, high blood pressure, and arthritis, and noted intact cognition with no behaviors. During observation, the resident was seated in her chair in her room and stated she had been at the facility for a while; numerous chips were observed on the walls directly behind her chair and on the right side of the bed, approximately 10 to 12 inches above the mattress. The resident stated the chips and scuffs had always been there since she moved in. The administrator stated the maintenance director used a TELS system to generate, assign, and track work orders and could track preventative maintenance, but was unsure whether a preventative maintenance schedule included resident rooms and agreed rooms should be checked yearly for maintenance needs. RN-A stated the resident was known to move things around in her room and was unaware of the scratches and chips behind the chair and beside the bed. QAPI meeting minutes from May 2025 through April 2026 showed environmental services data included painting as needed under Building Improvements, with action plans to touch up paint when rooms were empty or as needed. Safety meeting documentation showed monthly safety rounds were performed, but there was no mention of specific preventative maintenance checks to ensure resident rooms were maintained in a homelike manner. No policy related to preventative maintenance was provided by the end of survey.
Failure to Document Hospice Communication and Notes
Penalty
Summary
The facility failed to have documented communication between the facility and hospice in accordance with the written hospice agreement and failed to ensure hospice notes were included in the medical record for 1 resident receiving hospice services. The resident had a comprehensive MDS assessment identifying a re-admission to the facility in September 2024, with diagnoses of dementia, anxiety disorder, and moderately impaired cognition. The current care plan identified a terminal prognosis requiring hospice involvement and palliative care related to an end-stage disease process, with goals to maintain comfort, dignity, autonomy, and peacefulness. Review of the electronic medical record showed hospice notes, schedules, and care plans were present for some months, but there were multiple gaps with no notes captured for several extended periods. The hospice nurse stated hospice staff visited the facility twice weekly and that the facility was supposed to capture all documentation from each hospice visit in the medical record, but he was unsure why notes were missing. The facility RN stated staff had verbal communication with hospice but did not document that communication, and she was unaware that hospice notes were missing for several months. The hospice contract stated that hospice and the facility were to communicate regularly and document each communication in their respective clinical records to ensure the needs of hospice patients were met 24 hours per day.
Missing Required Alzheimer’s and Dementia Training for DON and NA-C
Penalty
Summary
The facility failed to ensure that 2 of 8 sampled staff members, the DON and NA-C, had initial or annual Alzheimer's and dementia training. Review of the Employee Roster and job/hire date documents showed the NA-C had a hire date of 2/23/26 and the DON had a hire date of 5/28/24. Review of their Alzheimer's Disease or Related Disorder Training records showed both staff members had not completed training covering an explanation of Alzheimer's disease and related disorders, assistance with activities of daily living, problem solving with challenging behaviors, or communication skills. During an interview on 5/19/26 at 4:25 p.m., the administrator stated that the 2 of the 8 staff had not completed their Alzheimer's training as required and expected the training to be completed initially and annually. The facility's undated New Hire Requirements for Relias orientation education listed dementia care topics, including understanding dementia, communication, actions and reactions, Alzheimer's/dementia versus normal aging, ADL assistance, challenging behaviors, and caregiver stress management. The 5/12/26 Facility Assessment identified staffing would be adequate for caring for residents with mental health conditions, history of trauma, and dementia, and the facility's training program for new and existing staff included dementia management, abuse prevention, effective communication, special needs of residents, and caring for residents who are cognitively impaired. A policy on the facility's Alzheimer's dementia training program for new hires and annual training was requested but not provided.
Failure to Notify Physician of Skin Alteration
Penalty
Summary
The facility failed to notify a physician of a significant skin alteration for one resident who was admitted with multiple bruises and an open area on the left great toe. Upon admission, the resident had intact cognition and was receiving treatment for a foot infection. Progress notes documented the development of new skin changes on the right foot, including discoloration, a large bump, and a fluid-filled blister. These changes were observed and measured by nursing staff over several days, with the area increasing in size and the skin becoming thin and transparent. Despite these documented changes, there was no evidence that the physician was notified of the new skin condition until several days after the initial observation. Interviews with facility staff confirmed that it was the expectation for nurses to notify the physician promptly when skin concerns arise. The physician only became aware of the wound during routine rounds, at which point medical intervention was initiated. Review of facility policy indicated that nurses are required to notify the physician or nurse practitioner immediately upon identifying a skin alteration, either by fax or phone, and to document the new order in the electronic health record. The delay in physician notification was not consistent with facility policy or staff expectations.
Failure to Ensure Annual Insulin Administration Competencies and Protocol Adherence
Penalty
Summary
The facility failed to implement its facility assessment to ensure that all licensed nurses, including one LPN and potentially eight others, who administered insulin had completed yearly competencies for safe insulin administration and identification of complications related to blood sugar levels. This deficiency was identified through interviews and document reviews, which revealed that the facility did not maintain up-to-date competency records for insulin administration or for recognizing and responding to hypoglycemia or hyperglycemia. The facility assessment did not specify that staff should be deemed competent at least yearly or more often as necessary, and there was no evidence of annual competencies for 2024 for the involved LPN. A resident with multiple comorbidities, including diabetes mellitus type 2, heart failure, chronic kidney disease, and hypertension, experienced a significant event related to improper insulin administration. The resident received rapid-acting insulin (Fiasp) and long-acting insulin (Glargine) prior to receiving his meal, contrary to manufacturer instructions and facility protocols. The resident was found sweating, drooling, and unable to answer appropriately after receiving insulin before his meal was served. Blood sugar monitoring showed a drop from 99 mg/dL to 68 mg/dL, and upon arrival at the emergency department, the resident's blood sugar was 33 mg/dL. The facility's progress notes lacked documentation of the resident's blood sugar at the time of the incident and did not specify what interventions were implemented before the resident was sent to the hospital. Interviews with nursing staff revealed uncertainty regarding protocols for insulin administration and management of low blood sugar. The LPN involved was not aware of the availability of glucagon injectable medication and did not follow the standing order protocol for severe hypoglycemia, instead attempting to give the resident juice and sugar packets. The facility's policies did not provide clear guidance on recognizing diabetic complications or following manufacturer guidelines for insulin administration. The director of nursing confirmed that the LPN did not follow proper procedures and that not all nursing staff had received annual competencies related to insulin administration.
Failure to Implement and Document Required PIP for Pain Management
Penalty
Summary
The facility failed to provide evidence of an effective Performance Improvement Project (PIP) focused on high-risk or problem-prone areas, as required by their QAPI program. Review of QAPI meeting minutes from June 2024 through March 2025 showed that although the committee selected pain management as a PIP topic, there was no documentation of data collection, analysis, evaluation of the concern, or development of an action plan throughout this period. The QAPI minutes for each month consistently lacked these essential components, indicating that the PIP process was not followed as outlined in the facility's own QAPI plan. An interview with the administrator confirmed that the QAPI committee had chosen pain management as the PIP project but had not developed an action plan or followed the required steps of the PIP process. The facility's QAPI plan specifies that PIPs should include data collection, root cause analysis, measurable goals, and an action plan, but these steps were not documented or implemented for the pain management project. This deficiency had the potential to affect all 43 residents in the facility.
Inaccurate MDS Assessments for Mental Illness and Hospice Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident, the diagnosis list indicated bipolar disorder and a Level II PASARR assessment confirmed criteria for severe mental illness. However, the significant change MDS did not correctly indicate the resident's PASARR status, marking that the resident had not been evaluated for serious mental illness, despite documentation to the contrary. This discrepancy was acknowledged by nursing staff, who confirmed the error in MDS coding. For another resident, the significant change MDS assessment failed to identify that the resident was on hospice care, despite medical records and care plans clearly documenting hospice admission and related interventions. Previous MDS assessments had correctly indicated hospice status, but the most recent significant change assessment omitted this information. The DON confirmed that the MDS did not accurately reflect the resident's hospice status.
Failure to Administer Rapid-Acting Insulin According to Manufacturer Instructions
Penalty
Summary
A deficiency occurred when a resident with diabetes mellitus type 2, chronic kidney disease, heart failure, and other comorbidities was administered rapid-acting insulin (Fiasp insulin aspart) in a manner inconsistent with manufacturer instructions. The resident's medication administration record showed that the insulin was given significantly before the meal, with documentation indicating the injection was administered approximately 45 minutes prior to the resident receiving his meal. Manufacturer guidelines specify that Fiasp insulin should be given at the start of a meal or within 20 minutes after starting a meal. The consulting pharmacist and director of nursing both confirmed that the insulin was not administered according to these guidelines. On the day of the incident, the resident was found sweating and drooling, with altered mental status, after receiving his insulin but before eating. Blood sugar readings documented a drop from 99 mg/dL to 68 mg/dL, and upon arrival at the emergency department, the resident's blood sugar was 33 mg/dL. The resident had a recent history of influenza and poor oral intake, yet the facility continued to administer his usual insulin doses without adjustment or provider consultation. The nurse on duty attempted to treat the hypoglycemia with orange juice and sugar packets but did not follow the facility's standing orders for severe hypoglycemia, which required the use of glucagon gel or injection if the resident was unresponsive or unable to swallow. Interviews with nursing staff revealed uncertainty regarding protocols for insulin administration and hypoglycemia management. The nurse involved was unaware of the availability of glucagon injection in the emergency kit and did not follow the standing order protocol. Review of facility policies and staff files indicated gaps in annual competency assessments and a lack of clear policy guidance on following manufacturer instructions for insulin administration or managing diabetic complications. The facility assessment did not specify requirements for maintaining staff competency at least yearly.
Unauthorized Resident Access to Medication Storage Room During Insulin Administration
Penalty
Summary
A licensed practical nurse (LPN) was observed bringing a resident into the medication storage room to administer insulin. The LPN primed a Humulin Kwik pen, checked the resident's blood sugar, administered 20 units of insulin to the resident's abdomen, and disposed of the needle in the sharps container. The LPN stated that she typically did not administer insulin in the medication room, but did so in this instance because she was the only licensed nurse on duty and needed to give all the insulins in the facility. She also mentioned that the resident had left the dining room before she could administer the insulin, prompting her to bring the resident into the medication room for the procedure. Further interviews revealed that the assistant director of nursing (ADON) had also previously taken residents into the medication room to provide privacy for insulin administration. The director of nursing (DON) was unaware that nurses had been bringing residents into the medication room for this purpose and acknowledged concerns regarding infection control and medication storage, particularly if a resident were left unattended in the room. Facility policy specifies that the medication supply is only accessible to licensed nursing personnel, authorized staff, or pharmacy personnel.
Staff Entered Kitchen Food-Prep Area Without Required Hair Net
Penalty
Summary
A nursing assistant (NA) entered the kitchen food preparation area without wearing a hair net while the cook was actively dishing up meals onto plates. The NA stood within two feet of the cook, obtained a meal tray, and exited the kitchen, all without a hair net. When questioned, the NA stated she did not believe nurse aides were required to wear hair nets and explained her presence in the kitchen was to retrieve a meal for a resident who changed their mind about dining location. The dietary manager confirmed that staff are only permitted to enter as far as the hand washing sink without a hair net, and that hair nets are required beyond that point in the serving area. The DON also stated that all staff entering the kitchen for any reason are expected to don a hair net. Although the facility did not have a specific policy on hair nets, they provided a protocol indicating that hair restraints or hats are required in the food-prep area to prevent hair from contaminating food or food-contact surfaces.
Insulin Administration in Medication Room Breaches Infection Control
Penalty
Summary
A licensed practical nurse (LPN) was observed administering insulin to a resident in the medication storage room, which is adjacent to the dining room. The LPN donned gloves, primed the insulin pen, checked the resident's blood sugar, administered the insulin injection, and disposed of the needle in the sharps container before removing gloves and returning the resident to the dining room. The LPN stated that this was not her usual practice, but due to being the only licensed nurse on duty with a trained medication aide, she administered all insulins in the facility that day and used the medication room for this purpose. Interviews with the assistant director of nursing (ADON)/infection control nurse and the director of nursing (DON) revealed that taking residents into the medication room for insulin administration had occurred before, sometimes to provide privacy. The DON was unaware of this practice and acknowledged it as an infection control concern with potential for cross-contamination. Facility policies reviewed indicated that medication storage areas are to be kept clean and only authorized personnel should be present, and that infection control practices are necessary to prevent the spread of infections.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for a minimum of 8 consecutive hours per day on three specific days, which had the potential to affect all 44 residents. The review of nursing staff schedules and time punches revealed that on 8/16/24, RN-A worked only 3.2 hours, and no other RN was documented to have worked that day. On 8/17/24, RN-B worked for 3.9 hours, with no evidence of another RN covering the remaining hours. On 8/18/24, there was no evidence of any RN working at all. Interviews with the business office manager confirmed the lack of RN coverage on these days. The manager noted that RN-C worked for 2.7 hours on 8/16/24, but this still did not meet the 8-hour requirement. The administrator, during a phone call, mentioned that the corporate office had informed them that the facility was allowed 4 free days per quarter without RN coverage according to the Provider Based Journal (PBJ) regulation. However, no policy related to RN coverage or staffing was provided by the end of the survey. The CMS expectation is that a citation should be issued if even one day does not meet the nurse staffing requirement.
Inappropriate Sling Use During Resident Transfer
Penalty
Summary
The facility failed to follow the manufacturer's safety instructions for safe transfers, resulting in a deficiency. A resident with severe cognitive impairment, aphasia, dementia, anxiety, and depression, who was dependent on staff for all activities of daily living except for partial assistance with dressing, was transferred using an inappropriate mechanical lift sling. The resident's care plan did not specify the size and type of sling required for transfers. Upon returning from the hospital, the resident was observed sitting in a wheelchair on a Guldmann ceiling lift sling, which was not compatible with the Volaro total body lift used by the facility staff. Two nursing assistants used the Guldmann sling with the Volaro lift to transfer the resident from the wheelchair to the bed without checking the tension of the sling straps. The nursing assistants were unaware that the Guldmann sling was not approved for use with the Volaro lift. The facility administrator confirmed that there was no policy regarding transferring residents, relying instead on staff competencies to ensure correct usage of mechanical lifts. The Valaro lift representative stated that only Volaro slings should be used with the Volaro lift, as per the manufacturer's instructions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tracy
How nearby facilities compare on the same public inspection record.
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|---|---|---|---|---|
| Good Samaritan Society - Westbrook | 15.5 mi | ★★★★★ | 11 | 0 |
| Valley View Manor Hcc | 17.1 mi | ★★★★★ | 13 | 2 |
| Avera Morningside Heights Care Center | 17.1 mi | ★★★★★ | 6 | 1 |
| Wabasso Restorative Care Center | 21.2 mi | ★★★★★ | 23 | 0 |
| Maple Lawn Senior Care | 24.7 mi | ★★★★★ | 10 | 0 |
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