Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Prairie View Skilled Nursing during CMS and state inspections, most recent first.
Ice machine drain line lacked a required air gap and was inserted directly into a floor drain, with water dripping into the drain. Surveyors also observed a bucket of discolored water on the floor and dust-covered silk arrangements on top of the machine. The Dietary Manager, Maintenance Supervisor, and Administrator each stated the drain line should have an air gap and that nothing unrelated to the ice machine should be placed on top of it.
Failure to Investigate and Reassess Choking Incident: A resident with dementia, dysphagia, and a prior choking history choked while eating, became unable to cough or speak, and required the Heimlich maneuver three times before the obstruction was expelled. The record showed no investigation of the event, no assessment of the cause, no review of whether existing diet and feeding interventions were effective, and no documentation of any changes to the care plan or supervision after the incident.
A resident with reflex neuropathic bladder had a urinary catheter placed by urology for urinary retention, but the chart lacked a current order for the catheter and for catheter care. The TAR also had no documentation of catheter care, although staff later provided catheter care during observation. The DON and an LPN stated there should be documented orders for both the catheter and catheter care.
The facility failed to obtain a physician's order for a resident with a colostomy, did not follow wound care orders for a resident with a cutaneous abscess, and did not follow PT, OT, and ST orders for two residents. Interviews confirmed these deficiencies were due to lack of proper documentation and verification.
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease. The resident's care plan included restorative care three times weekly, but multiple sessions were missed due to the Restorative Nurse Aide (RNA) being occupied with transportation duties. The Administrator acknowledged the need for better communication to ensure restorative tasks are completed.
The facility failed to ensure proper placement and coverage of a Foley catheter for a resident with urinary retention. Observations showed the catheter drainage bag hanging uncovered on the wheelchair armrest, contrary to policy. Staff interviews confirmed the correct procedure was not followed.
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 8.57%. A CMT did not administer a resident's Mucinex dose as ordered, administered only one Keppra tablet instead of two to another resident, and failed to prime an insulin pen before administering insulin to a third resident. The ADON confirmed that staff are expected to follow physician orders and prime insulin pen needles.
The facility failed to label and store medications properly, with multiple insulin pens found without opened or expiration dates. Interviews with staff confirmed that the responsibility for dating the pens lay with the CMTs, and that improperly labeled medications should be disposed of. This failure had the potential to affect all residents.
The facility failed to maintain proper infection control practices during medication administration, incontinent care, wound care treatment, and blood glucose monitoring for several residents. Staff did not follow hand hygiene protocols, did not change gloves between tasks, and did not properly disinfect equipment, increasing the risk of infection.
Ice machine drain line lacked required air gap
Penalty
Summary
The facility failed to ensure the ice machine drain line maintained a required air gap to prevent direct contact with the floor drain. Observations showed the ice machine located in the dining room had a round black plastic pipe connected from the back of the machine and inserted directly into a floor drain, with water dripping from the pipe into the drain. The observations also noted a bucket of discolored water on the left side of the floor and two silk arrangements with dust buildup on top of the ice machine. The facility’s policy titled, Ice Machine and Ice Storage Chests, revised January 2012, addressed maintaining a safe and sanitary supply of ice and listed sources of contamination, but it did not address the air gap required for the ice machine drain line. During interviews, the Dietary Manager, Maintenance Supervisor, and Administrator each stated the drain line should have a maintained air gap to prevent contamination from the floor drain, and that nothing unrelated to the ice machine should be placed on top of it.
Failure to Investigate and Reassess Choking Incident
Penalty
Summary
The facility failed to assess and investigate a choking incident involving a resident with dementia, a history of stroke, hemiplegia, dysphagia, anxiety, hypertension, PTSD, and psychotic disorder. The resident required partial/moderate assistance with eating, was on a mechanically altered diet, and had care plan interventions including mechanical soft diet with small portions, no bread or peanut butter sandwiches, one serving at a time, reminders to eat slowly, and monitoring for chewing and swallowing difficulties. The care plan also noted a prior choking episode that required the Heimlich maneuver. After the resident choked while eating in the dining room, turned red, could not cough or speak, and was unable to respond to verbal stimuli, staff performed the Heimlich maneuver three times before the resident expelled the obstruction and resumed breathing and speaking. The physician and responsible party were notified, but the record contained no documentation that the facility investigated the incident, assessed the cause, evaluated whether the existing choking interventions were effective, reviewed whether changes to the diet, supervision, feeding assistance, or care plan were needed, or implemented additional interventions. The resident continued to receive meals in the dining room after the incident, and the DON stated she was unaware the Heimlich maneuver had been required.
Missing Orders for Urinary Catheter and Catheter Care
Penalty
Summary
The facility failed to obtain a physician order for a urinary catheter and for catheter care for one resident. Resident #13 was admitted with a diagnosis of reflex neuropathic bladder, and urology placed a urinary catheter during a visit for urinary retention related to that condition. The urology note stated the catheter was placed with no additional orders or instructions, and the nurse’s note documented that the catheter was to remain in place for 30 days as tolerated. The resident’s physician order sheet did not contain a current order for the urinary catheter or for catheter care, and the treatment administration record had no documentation of urinary catheter care during the reviewed period. During interview, the resident stated the catheter had been placed by the urologist. On observation, staff provided urinary catheter care. The DON and an LPN stated there should be documented orders for a urinary catheter and catheter care.
Failure to Obtain and Follow Physician Orders
Penalty
Summary
The facility failed to obtain a physician's order for a resident with a colostomy, leading to the resident performing colostomy care independently without proper medical oversight. The resident, diagnosed with colostomy, ileostomy, COPD, anxiety, and schizophrenia, did not have an order for colostomy care or self-care in the Physician Order Sheet. Interviews with the ADON, DON, and Administrator confirmed that there should have been a physician's order for the colostomy care, which was not in place. The facility also failed to follow wound care orders for a resident with a cutaneous abscess of the limb, atherosclerotic heart disease, diastolic congestive heart failure, and acute pulmonary embolism and thrombosis of the lower extremity. The resident's treatment administration record showed missed wound care on two out of five opportunities, despite an order for daily dressing changes. The ADON admitted to scanning the orders into the system without verifying them, leading to the missed care. Additionally, the facility did not follow physician orders for PT, OT, and ST evaluations and treatments for two residents. One resident with arthritis and pain in the right hand did not receive the ordered therapy evaluations, and another resident with a stroke and dysphasia was not evaluated by therapy despite having an order. Interviews revealed that evaluations were not completed due to insurance issues and lack of documentation, and the facility's electronic medical records program had standing orders that were not followed through.
Failure to Provide Adequate Restorative Care for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease. Resident #8, who had diagnoses including muscle weakness, abnormal posture, and spinal stenosis, was dependent on staff for activities of daily living (ADLs) and self-care. The resident's care plan included restorative care three times weekly for 90 days to increase left hand splint tolerance, decrease flaccidity, increase strength in the left upper extremity, and maintain a sitting up position. However, the resident's restorative nursing documentation showed multiple missed opportunities for therapy in both March and April 2024, with six missed sessions in March and nine in April out of 12 opportunities each month. During interviews, the Restorative Nurse Aide (RNA) admitted to not completing the RNA tasks as ordered due to being occupied with transportation duties for the facility. The RNA stated that they tried to do as much as possible but were unable to fulfill all the required tasks. The Administrator acknowledged that the RNA needed to inform staff when they would be out of the facility so that someone else could complete the restorative tasks. This lack of communication and failure to provide the necessary restorative care led to the deficiency in maintaining and improving the resident's ROM.
Improper Foley Catheter Care
Penalty
Summary
The facility failed to ensure proper placement and coverage of the Foley catheter tubing and drainage bags for one resident. The resident, diagnosed with urinary retention, had a physician's order to change the Foley catheter monthly. Observations over several days showed the resident sitting in a wheelchair with the uncovered catheter drainage bag hanging on the right armrest of the wheelchair, contrary to the facility's policy which requires the drainage bag to be lower than the bladder and placed in a privacy bag. Interviews with staff, including a CNA, LPN, ADON, and DON, confirmed that the catheter bag should be placed under the wheelchair and always in a privacy bag. However, the CNA admitted to usually hanging the catheter bag on the armrest and was unaware if privacy bags were available. The LPN and ADON reiterated the correct procedure, and the DON confirmed the catheter drainage bag should be positioned lower than the bladder and in a privacy bag.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 8.57% for three residents. Certified Medication Technician (CMT) A did not administer Resident #1's Mucinex ER 600 mg dose in the morning as ordered. Additionally, CMT A administered only one Keppra 500 mg tablet to Resident #5 instead of the prescribed two tablets. Furthermore, CMT A failed to prime the lispro Kwik Pen before administering 14 units of insulin to Resident #22, as required by the manufacturer's instructions. During interviews, CMT A admitted to not administering the correct dosage of Keppra to Resident #5 and acknowledged being trained to prime insulin pen needles prior to injection. The Assistant Director of Nursing (ADON) confirmed that staff are expected to prime insulin pen needles and follow physician orders when administering medications. The facility's policy on administering medications did not address insulin pen administration techniques, contributing to the observed deficiencies.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to label and store medications in a safe and effective manner, which had the potential to affect all residents. During an observation of the medication cart, it was found that multiple insulin pens, including Humalog, lispro, Victoza, Ozempic, and Lantus, were labeled with residents' names but lacked opened or expiration dates. This was contrary to the facility's policies and the manufacturer's instructions, which require that multi-dose vials and pens be dated when opened and discarded after a specified period. Interviews with a Certified Medication Technician (CMT), the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator confirmed that the responsibility for dating the insulin pens when opened lay with the CMTs, and that medications not properly labeled should be disposed of. The facility's policies on medication labeling and storage, administering medications, and insulin administration were reviewed and found to be in place, but not followed. The CMT admitted to not always dating the insulin pens when opening them, and the ADON acknowledged that some insulin pens were good for 28 days while others for 30 days. The DON and the Administrator reiterated that medications should be dated when opened and disposed of if not properly labeled. This failure to adhere to proper medication labeling and storage protocols had the potential to affect all residents in the facility, which had a census of 34 at the time of the survey.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration for one resident. A Certified Medication Technician (CMT) handled multiple medications with bare hands and did not perform hand hygiene or wear gloves when handling medication bottles and tablets. This included placing a tablet back into a bottle used for multiple residents, which could lead to cross-contamination and infection risks for other residents using the same medication bottle. During incontinent care for another resident, two Certified Nursing Aides (CNAs) did not follow proper hand hygiene protocols. They failed to change gloves between dirty and clean tasks and did not perform hand hygiene after removing gloves. This included cleaning the resident's peri area and then handling clean briefs and bed linens with the same soiled gloves, increasing the risk of spreading infections. The facility also failed to maintain proper infection control during wound care treatment for a resident. The Assistant Director of Nursing (ADON) did not disinfect scissors used for wound care and did not perform hand hygiene between glove changes. Additionally, the ADON placed wound care supplies on an incontinent pad without a clean barrier, further compromising infection control. Similar lapses were observed during blood glucose monitoring for three residents, where the CMT did not follow proper disinfection procedures for the glucometer and failed to perform hand hygiene before and after the procedure.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crowley Ridge Care Center | 5.3 mi | ★★★★★ | 0 | 0 |
| Cypress Point-skilled Nursing By Americare | 6.4 mi | ★★★★★ | 0 | 0 |
| Memory Lane Of Dexter | 6.9 mi | ★★★★★ | 6 | 0 |
| Puxico Nursing And Rehabilitation Center | 13.1 mi | ★★★★★ | 5 | 0 |
| Aspire Senior Living Advance | 15.1 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.