Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Prairie House Living Center during CMS and state inspections, most recent first.
Failure to Report Alleged Resident-to-Resident Abuse: The facility did not report an alleged resident-to-resident abuse incident involving two residents with significant cognitive impairment and behavioral issues. Staff documented that one resident pushed the other out of a room and almost caused a fall, and multiple staff said the event was reportable. The ADM did not notify the state because he concluded the contact was guidance rather than abuse, despite the facility policy requiring immediate reporting of alleged abuse.
Food Items Not Properly Labeled, Dated, or Stored: The kitchen pantry, prep area, deep freeze, freezer, and refrigerator contained multiple food items that were not labeled or dated, including cereal, ice cream, dinner rolls, ground beef patties, seafood patties, bologna, pimento cheese, and cheese. Dried onion pieces were also observed on the pantry floor and on top of food containers. The DM, an employee, and DA G stated that staff were responsible for proper labeling, dating, covering, and storage of food, and facility policy required food to be stored neatly and in covered, labeled, and dated containers.
A resident rights deficiency was cited after surveyors observed a sticky substance on the activity lounge floor across multiple checks, hanging ceiling texture in the main dining room, and dirty, damaged, and broken items in the memory care dining area, including ceiling fans, light fixtures, chairs, and tables. Staff interviews showed awareness of several of the environmental issues, and the facility policy required a safe, clean, comfortable, and homelike environment.
A facility failed to complete accurate, person-centered care plans for three residents. Two residents had bed rails installed and in use, with assessments and education forms in the record, but their care plans did not mention the bed rails. A third resident’s care plan also omitted bed rails and incorrectly stated she was receiving an anticoagulant when the MAR and order summary showed no anticoagulant medication.
A facility failed to provide safe respiratory care for multiple residents who required O2. Several residents with COPD, chronic respiratory failure, stroke-related conditions, and other diagnoses were repeatedly observed with nasal cannulas left on the floor or otherwise not stored in a bag off the floor, while staff described expected practices for storing and replacing contaminated tubing. The facility also failed to provide O2 for one resident.
Loose bedrails were observed for three residents with bedrails in use. One resident with stroke-related deficits and intact cognition, one resident with intact cognition and multiple serious diagnoses, and one resident with severely impaired cognition and extensive ADL assistance all had upright rails that rotated when tested. The report also noted that the facility policy required correct installation, use, and maintenance of bed rails, including inspection to ensure rails had not become stiff or loosened over time.
Infection control precautions were not consistently followed during resident care. An LVN entered rooms with precaution signs without proper PPE or with a gown not secured, administered meds, checked a foley catheter, obtained vital signs, and used shared equipment without fully cleaning the blood pressure cuff. Two CNAs also performed catheter care in a room marked for EBP precautions without wearing gowns. Interviews showed confusion among staff about the difference between contact and EBP precautions, and the ADON stated the wrong precaution signs had been placed on doors.
Menu items were not followed for residents on pureed diets. Residents were served a substituted dessert instead of the posted dessert, and on another meal, pureed toast was omitted from breakfast trays even though the approved menu listed it. The DM acknowledged the dessert substitution was undocumented, an employee said he forgot to puree the toast for the affected residents, and the RD stated substitutions should have been approved by her. The affected residents had orders and care plans for pureed diets and significant cognitive impairment or other chronic conditions.
An LVN failed to follow standard and precaution-based infection control practices while giving meds, checking a Foley catheter, and starting IV vancomycin for a resident with a PICC line, including not securing PPE, not cleaning the PICC port, and not fully cleaning reusable equipment. Two CNAs also performed catheter care for a resident with a Foley catheter without wearing gowns despite EBP signage. Staff interviews showed confusion about EBP versus contact precautions and acknowledgment that the wrong precaution signs had been posted.
A resident with a history of CVA, hemiplegia, and seizures was coded on the MDS and in the care plan as receiving an anticoagulant, even though the MAR and order summary showed no anticoagulant medication. The MDS LVN stated the coding was her error because she thought clopidogrel was an anticoagulant, and staff confirmed she was responsible for completing MDS assessments.
Baseline Care Plan Omitted Bedrails: A resident admitted with metabolic encephalopathy, leukemia/lymphoma in remission, and lumbar osteomyelitis had a baseline care plan that did not include bedrails, even though siderail education was signed, a bed rail assessment was completed, and bedrails were installed and observed in use. Staff stated the nursing department was responsible for including bed rails in care plans and that incomplete care plans could affect resident care.
A resident with a PICC line and diagnoses including osteomyelitis and cancer in remission did not have PICC dressing change, flushing, or infection-monitoring orders documented on the MAR/TAR despite the care plan and physician orders calling for IV therapy management. Staff observed and administered PICC care, and interviews showed the DON noticed the missing orders and entered them later, while staff acknowledged that lack of orders could result in the dressing not being changed and could lead to infection.
Failure to identify PTSD triggers in care plan: A resident with PTSD, anxiety, bipolar disorder, and major depressive disorder had intact cognition, but her care plan did not include PTSD, trauma history, triggers, or trauma-informed interventions. The trauma screening was not updated after the PTSD diagnosis was identified, and the DON, SW, and nursing staff were unaware of the diagnosis or any triggers; the resident stated her PTSD was related to childhood trauma.
The facility failed to maintain sanitary conditions in resident refrigerators, leading to the presence of expired and unlabeled food items. Observations revealed open and expired food packages, moldy sandwiches, and unlabeled condiments. Interviews with staff, including a CNA, DM, LVN, RN, and ADON, showed a lack of clarity regarding responsibility for refrigerator maintenance. The facility's policies on food storage and labeling were not followed, putting residents at risk of foodborne illnesses.
A resident with severe cognitive impairment and an indwelling catheter was observed with an uncovered catheter bag visible from the hallway, compromising their dignity. Facility staff confirmed that catheter bags should be covered to prevent dignity issues, as per the facility's policy on resident rights.
The facility failed to document necessary fall prevention measures in the care plans of two residents, despite their identified fall risks. One resident's care plan lacked documentation of a scoop mattress, while another's did not include a fall mat, even though both were observed in use. Staff interviews highlighted the potential for inadequate care due to these omissions.
The facility failed to provide appropriate respiratory care for two residents, as one did not have physician orders for oxygen therapy and the other lacked a specified oxygen rate in her orders. Observations showed both residents receiving oxygen without proper documentation, which was confirmed by nursing staff. The absence of specified orders was acknowledged as a medication error and a treatment issue, potentially impacting the residents' care.
Failure to Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an alleged resident-to-resident abuse incident was reported immediately, and no later than 2 hours after the allegation was made, to the administrator and other required officials, including the State Survey Agency and adult protective services as applicable. The deficiency involved 2 of 7 residents reviewed for abuse, identified as Resident #1 and Resident #2, after an incident on the memory unit in which Resident #1 was documented as pushing Resident #2 out of a room and almost causing her to fall. The incident report identified Resident #1 as the perpetrator, and the facility record also documented that the event was not witnessed. Resident #1 was a male with diagnoses including dementia with severe behavioral disturbance, anxiety, paranoid schizophrenia, and psychotic disorder with delusions. His quarterly MDS showed a BIMS score of 04, indicating severe cognitive impairment. His care plan documented physical and verbal aggression toward staff and/or other residents, and a progress note stated that he pushed another resident and almost made her fall down. Resident #2 was a female with diagnoses including unspecified dementia with severe behavioral disturbance, mild cognitive impairment, and Alzheimer’s disease. Her care plan documented impaired cognition, physical behaviors, and rummaging behaviors. Her progress note stated that she was pushed by another resident and almost fell down. During interviews, multiple staff members stated the incident was reportable and described possible negative outcomes of not reporting abuse, including injury, continued abuse, and residents being harmed. The ADON stated she was present in the memory unit when the incident occurred and that the incident was reported to the ADM and DON in person, but she was unaware whether the chain of reporting was followed. The DON stated he knew about the incident and acknowledged it, but said Resident #1 did not push Resident #2 down and that there was no harm. The ADM stated he did not report the incident because he determined Resident #1 did not push or shove Resident #2 and believed the event was not abuse, although he also stated he investigated the incident. The facility policy required reporting all alleged violations involving resident-to-resident altercations involving allegations of abuse immediately, but not later than 2 hours after the allegation is made.
Food Items Not Properly Labeled, Dated, or Stored
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During observation of the pantry on 02/24/2026 at 9:16 AM, dried onion pieces were seen on the floor and on top of food containers. In the preparation area at 9:20 AM, 12 covered bowls containing what appeared to be breakfast cereal were observed without labels or dates. In the deep freeze at 9:21 AM, 14 cups containing what appeared to be ice cream were observed without labels or dates. Additional observations in the freezer near the pantry at 9:25 AM showed 1 box of dinner rolls opened to air without a label or date, 1 box of ground beef patties without a date, and 1 box of seafood patties with visible ice crystals and no date. In the refrigerator at 9:30 AM, 1 box containing seven packages of bologna was not dated, 1 gallon container of pimento cheese had no open date, and 1 box containing what appeared to be cheese was not labeled or dated. The DM, [NAME] A, and DA G each stated that it was everyone's responsibility to label, date, cover, and store food properly, and the DM stated she was responsible for ensuring staff complied with labeling and dating requirements. Facility policies for dry goods and cold food storage stated that food items were to be stored neatly, labeled and dated as appropriate, and kept in covered containers to prevent cross contamination.
Unsafe and Unclean Resident Dining and Lounge Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in the resident lounge, main dining room, and memory care dining area. During observations, surveyors found a sticky orange and brown dried substance on the floor of the resident activity lounge that remained in place across multiple observations over several days. In the main dining room, two areas of ceiling texture were hanging down above tables, and in the memory care dining area, ceiling fans were dirty with dust hanging from the blades, light fixtures were dirty with cobwebs, and one light fixture above a dining table was cracked and broken. The memory care dining area also had furniture in poor condition. One chair had split cushion covering with cushion coming out, six of seven tables had stripping on the sides coming off, and chairs in the dining area were dirty and needed cleaning. Surveyors observed these conditions on multiple occasions, including after the issues had already been noted. Staff interviews confirmed awareness of several of the concerns, including the ceiling in the main dining room, dirty fans, dirty and worn chairs, broken light fixture, and tables needing repair, while some staff stated they had not noticed certain issues before the survey observations. Record review of the Resident Rights policy dated 02/23/2016 stated that residents have a right to a safe, clean, comfortable, and homelike environment, including receiving treatment and supports for daily living safely. The report documents that the observed environmental conditions remained present during the survey period and were identified as not meeting that standard.
Incomplete Care Plans Omitted Bed Rail Use and Included Incorrect Medication Information
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents by omitting bed rails from their care plans, and in one case by documenting an anticoagulant that the resident was not receiving. Resident #10 had diagnoses including multiple rib fractures, dementia with agitation, and Alzheimer’s disease, with a BIMS score of 9 and assistance needs across ADLs. Her record showed bed rails were installed and a bed rail assessment had been completed, and observations confirmed one upright bedrail on the right side of her bed, but her care plan did not mention bed rails. Resident #62 had diagnoses including congestive heart failure, acute respiratory failure with hypoxia, and paroxysmal atrial fibrillation, with a BIMS score of 9 and dependence or supervision needs across ADLs. Her record also showed bed rails were installed and assessed, and observations repeatedly confirmed upright bedrails on both sides of her bed, but her care plan did not mention bed rails. Resident #27 had diagnoses including cerebral infarction, left-sided hemiplegia/hemiparesis, and seizures, with a BIMS score of 15 and partial to moderate assistance needs for toileting, lower body dressing, transfers, and bed mobility. Her care plan did not mention bed rails, even though the record showed a siderail education form was signed, a bed rail evaluation was completed, and observations found upright bedrails on both sides of her bed. During an interview, she stated she used the bedrails to move around in bed and that they had been on her bed since admission. Resident #27’s care plan also stated she was currently taking an anticoagulant related to CVA, but the order summary report and MAR showed no anticoagulant medication. During interviews, facility staff stated that incomplete or inaccurate care plans could result in residents receiving incomplete or inaccurate care, and the MDS LVN stated she had mistaken an antiplatelet medication for an anticoagulant medication. Facility policy required comprehensive person-centered care plans with measurable objectives and timeframes, and the bed rail policy required specific interventions and services for bed rail use to be documented in the care plan.
Respiratory Equipment Not Properly Stored and Oxygen Not Provided
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents who required oxygen therapy. The deficiency involved five residents reviewed for respiratory care, including residents with diagnoses such as COPD, chronic respiratory failure, cerebral infarction, CHF, aphasia, dysphagia, paraplegia, and other significant medical conditions. Several of these residents were documented as requiring oxygen while a resident, and their care plans identified oxygen use and ineffective gas exchange as ongoing concerns. For Resident #2, Resident #4, Resident #18, and Resident #83, surveyors repeatedly observed their nasal cannulas on the floor when the residents were not using them. Resident #2’s oxygen concentrator was present and turned on at 2 L/min, but the nasal cannula was on the floor during multiple observations. Resident #4’s oxygen equipment was also present, and her nasal cannula remained on the floor during several observations; later, when she was observed eating breakfast with oxygen on, the tubing had no date and the hydration bottle was still dated 2-22. Resident #18 was observed with his oxygen concentrator present but not wearing oxygen, and his nasal cannula was on the floor during repeated observations; he stated staff changed his equipment the prior Sunday and later demonstrated putting the cannula back on the floor. Resident #83 was observed with her cannula on the floor, later moved to the top of the concentrator but not stored in a plastic bag, and later observed sleeping with oxygen in place; the tubing had no date. The facility also failed to provide oxygen for Resident #30. In addition, the record review and interviews showed there were no care plan interventions for respiratory equipment care, including nasal cannula storage, for the residents identified. CNA staff and the ADON stated that nasal cannulas for residents not present in the room should be stored in a bag off the floor, and that a cannula found on the floor should not be used on a resident because it was contaminated and could cause infection. The DON stated staff were expected to round every two hours, store nasal cannulas off the ground in a bag, and replace a cannula found on the floor, but reported she was not aware staff had been trained on proper nasal cannula storage.
Loose Bedrails Observed for Three Residents
Penalty
Summary
The facility failed to ensure correct installation, use, and maintenance of bedrails for 3 residents reviewed for bedrails: Resident #27, Resident #29, and Resident #33. The report states that each of these residents had upright bedrails in place, and each had a bedrail that was loose when observed by surveyors. The facility policy titled Bed Rails required that if a bed or side rail is used, the facility must ensure correct installation, use, and maintenance, including inspecting bed rails to ensure they have not become stiff or loosened over time. Resident #27 was a female with diagnoses including cerebral infarction, left-sided hemiplegia and hemiparesis, and seizures. Her admission record showed intact cognition with a BIMS score of 15, and her functional assessment showed she required partial to moderate assistance for toileting, lower body dressing, transfers, and moving between sitting and lying. Her care plan did not mention bed rails, but she signed a siderail education fact sheet and had a bed rail evaluation completed. During observation, she was in bed with the head of the bed raised and stated she used the bedrails to move around in bed. She said the right bedrail had recently become loose and demonstrated that it rotated approximately 30 degrees in either direction. Resident #29 was a male with diagnoses including metabolic encephalopathy, adult T-cell lymphoma/leukemia in remission, and osteomyelitis of the lumbar spine. His admission MDS showed a BIMS score of 15, indicating intact cognition. His baseline care plan and order summary did not mention bedrails, but he signed a siderail education fact sheet and had a bed rail assessment showing the rails were installed as a mobility assist. During observation, he was lying in bed and stated he used the bedrails to get up from bed. He said the left bedrail was a little loose and demonstrated that it rotated approximately 30 degrees in either direction. Resident #33 was a male with diagnoses including after care following joint replacement surgery, Down Syndrome, and repeated falls. His annual MDS showed a BIMS score of 3 and extensive assistance needs across most ADLs. His care plan included bed mobility assistance using rails on both sides of the bed, and his family member had signed consent for bed rail use. During two observations, his bed had upright rails on both sides, and the left rail rotated approximately 30 degrees and then approximately 40 degrees in both directions.
Infection Control Precautions Not Followed During Resident Care
Penalty
Summary
The facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and maintain the highest practicable physical well-being for 1 of 1 facility reviewed for infection control procedures. Surveyors observed staff not implementing and maintaining appropriate infection control precautions during resident care, including improper use of PPE and incomplete cleaning of equipment used between residents. During an observation on 02/25/2026 at 7:00 AM, an LVN entered a room marked for EBP precautions to administer medications. The LVN placed a gown for EBP but did not tie or secure the back of the gown, administered the resident’s medications, and checked the resident’s foley catheter placement on the wheelchair. After removing PPE and using ABHR, the LVN cleaned equipment but did not use a wipe on the inner portion of the blood pressure cuff. Later that morning, the LVN entered a room marked for contact precautions without PPE, administered medications, obtained vital signs including BP, HR, temperature, and O2 saturation, and assessed pedal pulses on both legs. When the LVN later entered another room marked for contact precautions to administer IV vancomycin, she again placed gown and gloves before entry but did not tie or secure the gown upon entry. At 2:36 PM, two CNAs performed catheter care in a room marked for EBP precautions and neither CNA wore a gown during the care. In interviews, the CNAs stated they had been trained on infection control and precautions, but one CNA said she was not sure of the difference between EBP and contact precautions. The LVN stated she did not wear the appropriate PPE in one resident’s room because she did not touch the resident, and she acknowledged that failing to clean the blood pressure cuff properly could allow cross contamination. The ADON stated she had placed the wrong precaution signs on doors and that residents who were marked as contact precautions should have been listed as EBP precautions. The DON stated staff were expected to know the differences between contact and EBP precautions and to clean all sides of shared equipment such as blood pressure cuffs.
Menu not followed for residents on pureed diets
Penalty
Summary
The facility failed to follow the posted menu for residents receiving pureed diets. On 02/24/2026, the lunch menu posted in the main dining room listed vanilla pudding for dessert, but residents on pureed diets were served a peach-colored dessert instead. Residents #8, #21, #65, #69, and #85 were all identified as receiving pureed diets, and they were observed with the substituted dessert on their trays. During interview, the DM stated that residents on pureed diets eat pureed fruit better than cake, so peaches were substituted, and also stated that the substitution book indicated lemon bars were to be served in place of a cookie for dessert. The DM acknowledged there was no documentation of a dessert substitution for residents receiving a pureed diet and stated it was her responsibility to ensure the cooks were following the menus. The facility also failed to provide the ordered breakfast menu item to residents receiving pureed diets on 02/25/2026. During observation in the main dining room, Resident #85 and Resident #65 were eating breakfast trays that contained scrambled eggs, sausage, and cream of wheat, but the meal ticket indicated wheat toast should also have been served. The posted approved menu for breakfast listed scrambled eggs, sausage, cream of wheat, and wheat toast. An employee stated he forgot to puree the toast for the five residents receiving pureed diets and acknowledged it was wrong not to provide the full menu, stating that not providing all menu items could result in residents going hungry. Record review showed that each of the five residents had diagnoses and care plans supporting a pureed diet order, including dementia, dysphasia, Parkinson disease, stroke-related hemiplegia, and other chronic conditions. Their quarterly MDS assessments reflected severe cognitive impairment or inability to complete the interview, and their active orders and care plans directed staff to provide and serve the pureed diet as ordered. The RD stated she was not aware substitutions were being made and that any substitutions should have been approved by her, while the DM stated the residents should have had toast on their plates and that staff were supposed to follow the menu as written. The facility policy stated that meals are to be assembled in accordance with individualized diet orders, plan of care, and preferences.
Infection Control Lapses During PPE Use, IV Access Care, and Catheter Care
Penalty
Summary
The facility failed to maintain infection prevention and control practices during multiple resident care encounters. During an observation, an LVN entered a resident’s room with EBP signage, put on a gown and gloves but did not tie or secure the gown, administered medications, checked the resident’s Foley catheter placement on the wheelchair, removed PPE, used ABHR, and cleaned equipment without cleaning the inner portion of the blood pressure cuff. In a separate observation, the same LVN entered another resident’s room with contact precaution signage and did not put on any PPE before administering medications, obtaining vital signs, and assessing pedal pulses on both legs. Resident #29 was admitted with osteomyelitis of the vertebrae and had orders for PICC line monitoring and IV vancomycin. The resident’s care plan identified EBP due to a central or PICC IV line and active infection with MDRO precautions, as well as IV therapy risks. During observation, the LVN placed gown and gloves before entering the room but did not secure the gown and did not wipe the PICC line port with alcohol rub before connecting the IV vancomycin tubing and starting the infusion. The LVN later stated that not cleaning the IV port and the blood pressure cuff could allow cross contamination of infection between residents, and that not securing the gown could be an issue because it could get caught and expose the nurse to infection. Resident #8 had diagnoses including metabolic encephalopathy, diabetes, dementia, chronic kidney disease, and incontinence, and the record showed a Foley catheter order and a care plan identifying urinary catheter-related infection risk. During catheter care, CNA L and CNA M did not place a gown on when entering, during, or after the care despite EBP signage posted on the door. In interview, both CNAs stated they believed the resident did not require EBP because the signage was for the roommate, but later acknowledged that a resident with a catheter should have been on EBP and that they should have worn a gown. The ADON stated the wrong precaution signs had been used on doors and that the facility did not have any residents on contact precautions, while the DON stated staff should know the differences between contact and EBP precautions and that equipment such as blood pressure cuffs must be cleaned on all sides.
Inaccurate MDS Coding of Anticoagulant Use
Penalty
Summary
The facility failed to ensure Resident #27’s assessment accurately reflected her medication status when the MDS coded her as receiving an anticoagulant even though record review showed no anticoagulant medication on the Order Summary Report or the December 2025 MAR. Resident #27 was a female with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting the left non-dominant side, and seizures. Her admission MDS with an ARD of 12/27/25 and completion date of 01/06/26 showed a BIMS score of 15 and coded Section N to indicate anticoagulant use. The care plan completed on 12/24/25 also stated that Resident #27 was currently taking an anticoagulant related to CVA. During observation on 02/24/26, she was seated in her wheelchair in the hallway outside her room and stated the bruises on her left hand were from taking blood thinners and getting shots. Staff interviews identified that the MDS LVN was responsible for completing MDS assessments, and the MDS LVN stated the anticoagulant coding was her error because she thought clopidogrel was an anticoagulant. The Long-Term Care Facility RAI 3.0 User’s Manual stated that medications are to be coded according to their pharmacological classification.
Baseline Care Plan Omitted Bedrails
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #29 within 48 hours of admission that included the instructions needed to provide effective and person-centered care. Resident #29 was admitted with diagnoses including metabolic encephalopathy, adult T-cell lymphoma/leukemia in remission, and osteomyelitis of the lumbar spine. The admission MDS showed a BIMS score of 15, indicating intact cognition. The resident’s baseline care plan, initiated on 02/05/26, did not mention bedrails, even though the resident had signed a siderail education fact sheet on 02/05/26 acknowledging the risks of bedrail use. Record review showed Resident #29 was assessed for bed rail use as a mobility assist on 02/06/26 and the bedrails were installed on 02/06/26. The Order Summary Report did not mention bedrails. Observations on 02/24/26 and 02/25/26 showed bedrails present on both sides of the resident’s bed in the upright position, and during an interview on 02/25/26 the resident stated he used the bedrails to get up from bed. Facility staff, including the LVN, CNA, ADON, DON, and MDS LVN, stated that incomplete or inaccurate care plans could affect resident care and that the nursing department was responsible for including bed rails in care plans.
PICC Line Care Not Ordered or Documented
Penalty
Summary
The facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident’s goals and preferences for one resident with a PICC line. The resident was admitted with diagnoses including metabolic encephalopathy, adult T-cell lymphoma/leukemia in remission, and osteomyelitis of the lumbar spine. The admission MDS showed a BIMS score of 15, indicating intact cognition. The baseline care plan identified that the resident required IV therapy and was at risk for site infiltration, infection, fluid overload, pain, and other complications, and it directed staff to administer IV therapy and flushes as ordered, change the IV site dressing according to facility policy, and monitor the site for dislodgement, swelling, redness, pain, streaking, and drainage. Record review showed that the resident’s order summary included orders for PICC site dressing changes, daily monitoring of the PICC insertion site for signs and symptoms of infection, normal saline flushes twice daily, and IV antibiotics through the PICC line. However, the MAR and TAR reviewed did not show orders for PICC line dressing change, flushing, or monitoring for infection. During observation, the resident’s PICC line was partially visible under the sleeve of his shirt, and later a nurse flushed the PICC line and administered medication, stating the dressing had already been changed and there was no sign of infection. During interviews, the LVN, ADON, DON, and LVN K stated that PICC line care, including dressing changes and flushing, was performed by certified nurses or the wound care nurse, and that lack of physician orders could result in the dressing not being changed and could lead to infection. The DON stated she noticed on 02/24/26 that the resident did not have orders for PICC line care, dressing change, or flushing and entered the orders at that time. The resident stated the PICC dressing had been changed only once since admission. Facility policies reviewed stated that PICC flushing should be performed as ordered by the physician, transparent dressings should be changed every 7 days and as needed, and IV therapy should follow practitioner orders.
Failure to Identify PTSD Triggers in Care Plan
Penalty
Summary
The facility failed to ensure Resident #6, a [AGE]-year-old female with diagnoses including PTSD, anxiety disorder, bipolar disorder, and major depressive disorder, received trauma-informed and culturally competent care. Her quarterly MDS dated 11/20/2025 showed a BIMS score of 15, indicating intact cognition, and her comprehensive care plan last revised on 11/08/2025 did not include PTSD as a focus area or identify trauma history, potential triggers, or individualized trauma-informed interventions related to her PTSD diagnosis. Record review showed the facility’s Comprehensive Trauma Screening dated 08/27/2024 indicated Resident #6 did not have PTSD, and no updated trauma assessment was completed after the PTSD diagnosis was identified. During interviews, the DON stated she was unaware the resident had PTSD and said she would need to research trauma-informed care; the SW stated she was responsible for trauma assessments but was unaware of the diagnosis and did not know of any triggers; and other nursing staff and the MDS LVN stated they were unaware of the resident’s PTSD or triggers and believed PTSD and related interventions should be included in the care plan. The resident stated she had PTSD related to childhood trauma and avoided elaborating further.
Failure to Maintain Sanitary Conditions in Resident Refrigerators
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents, specifically in maintaining the cleanliness and safety of resident refrigerators. During an observation, it was found that the resident refrigerator located by the main nurse's station contained expired and rotten food items. These included open packages of taquitos and chicken strips, frozen breakfast meals past their expiration date, and unlabeled ice cream bars and drinks. Additionally, the main refrigerator contained expired salad bags, moldy sandwiches, and unlabeled condiment containers. Interviews with various staff members, including a CNA, DM, LVN, RN, and ADON, revealed a lack of clarity and communication regarding the responsibility for maintaining the resident refrigerator. None of the staff members interviewed were aware of who was responsible for cleaning and organizing the refrigerator. The DM mentioned that the nursing staff was supposed to maintain the refrigerator, but this was not communicated effectively to the staff. The staff also acknowledged that expired and unlabeled foods could expose residents to foodborne illnesses. The facility's policies on food storage and labeling were not adhered to, as evidenced by the presence of expired and unlabeled food items in the refrigerators. The policy stated that the task of keeping personal foods stored safely and sanitarily was the responsibility of the facility staff, and all foods should be labeled and dated. However, the lack of enforcement and communication of these policies contributed to the deficiency, putting residents at risk of foodborne illnesses due to the unsanitary conditions of the refrigerators.
Uncovered Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident's catheter drainage bag was covered, which compromised the resident's dignity and quality of life. The resident, a male with severe cognitive impairment and an indwelling catheter, was observed with his catheter bag uncovered and visible from the hallway. This observation was made during catheter care performed by a CNA, and later when the resident was asleep in his room with the door open. Interviews with facility staff, including an LVN, CNA, and RN, confirmed that catheter bags should be covered at all times to prevent dignity issues. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity, and staff are expected to be educated on these rights. Despite this policy, the uncovered catheter bag was noted, indicating a lapse in adherence to the facility's standards for resident care.
Failure to Document Necessary Fall Prevention Measures in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which did not address specific needs identified in their assessments. Resident #69, a cognitively intact male with a history of coordination issues and partial paralysis, was identified as a moderate fall risk. Despite observations of a contoured bed with raised edges, his care plan did not document the use of a scoop mattress, which was necessary to mitigate his fall risk. Similarly, Resident #12, a female with severe cognitive impairment and balance issues, was also identified as a moderate fall risk. Her care plan lacked documentation of a fall mat, even though observations confirmed its presence beside her bed. Interviews with facility staff, including an LVN and the ADON, revealed that the absence of these interventions in the care plans could lead to inadequate care for the residents. The ADON acknowledged the responsibility for ensuring that interventions like scoop mattresses and fall mats are documented in care plans. The facility's policy mandates regular reviews and updates of care plans to reflect residents' needs, but these were not adhered to, resulting in the deficiencies noted during the survey.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, Resident #66 and Resident #68, as per professional standards. For Resident #66, the facility did not obtain physician orders for her oxygen therapy, despite her being on oxygen therapy as indicated in her care plan. Observations revealed that Resident #66 was using oxygen at 3.5 liters per minute (lpm) without a corresponding physician order, which was confirmed by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). This lack of orders was acknowledged as a medication error and a treatment issue that could negatively impact the resident's care. Resident #68's care was also deficient as her physician's order for oxygen therapy did not specify the rate at which the oxygen should be administered. Despite being on oxygen therapy for conditions such as emphysema and chronic obstructive pulmonary disease (COPD), the facility's records did not include the necessary liters per minute (lpm) specification. Observations showed that Resident #68 was receiving oxygen at 4.25 lpm, but without a physician's order specifying this rate, which was confirmed by the nursing staff and the DON. The absence of a specified oxygen rate in the orders was recognized as potentially harmful, especially for a resident with COPD, as it could lead to adverse effects such as increased CO2 levels. The facility's policies on oxygen administration and medication treatment documentation were not adhered to, as evidenced by the lack of verification of physician orders and the absence of specified oxygen flow rates. The nursing staff, including the DON and Assistant Director of Nursing (ADON), acknowledged the deficiencies and the potential negative impact on the residents' quality of care. The failure to follow established procedures for verifying and documenting oxygen therapy orders contributed to the deficiencies observed in the care of Residents #66 and #68.
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Nursing homes near Plainview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plainview Healthcare Center | 1.3 mi | ★★★★★ | 9 | 0 |
| Runningwater Draw Care Center, Inc. | 22.3 mi | ★★★★★ | 6 | 0 |
| Sunset Valley Rehabilitation And Healthcare Center | 39.2 mi | ★★★★★ | 15 | 0 |
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