Inspection Reports for
Prairie View Skilled Nursing
606 WEST MISSOURI ST, BLOOMFIELD, MO, 63825-9706
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
14.2 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
158% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
77% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 46
Deficiencies: 7
Date: Apr 3, 2025
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with federal regulations related to resident transfer/discharge notifications, bed-hold policies, behavioral health services, medication management, insulin administration, and dietary services.
Findings
The facility was found deficient in multiple areas including failure to provide written transfer/discharge notices to residents and representatives, failure to inform residents of bed-hold policies in writing, inadequate trauma-informed care for a resident with PTSD, failure to reconcile narcotics properly, medication errors related to insulin administration, and failure to employ a qualified dietary manager.
Deficiencies (7)
Failed to provide written notice of transfer or discharge to residents and/or their representatives for three residents.
Failed to inform residents and representatives in writing of the facility's bed-hold policy at the time of hospital transfer for three residents.
Failed to identify, assess, and provide supportive interventions for a resident with PTSD, including lack of documentation of trauma triggers and incomplete behavioral health assessments.
Failed to ensure narcotics were reconciled at each shift change and failed to accurately administer, document, dispose of, and reconcile medications for one resident.
Failed to maintain medication error rate below 5%, with errors in insulin administration including failure to check blood sugar prior to administration and incorrect dosing.
Failed to ensure a resident was free from significant medication errors related to insulin administration without checking blood sugar prior to administration.
Failed to employ a qualified director of food and nutrition services; the Dietary Manager lacked required certification and experience.
Report Facts
Facility census: 46
Narcotic count reconciliation missed opportunities: 16
Narcotic count reconciliation missed opportunities: 25
Narcotic count reconciliation missed opportunities: 37
Narcotic count reconciliation missed opportunities: 15
Narcotic count reconciliation missed opportunities: 6
Narcotic count reconciliation missed opportunities: 12
Narcotic count reconciliation missed opportunities: 31
Narcotic count reconciliation missed opportunities: 41
Medication error rate: 10.71
Medication administration opportunities: 28
Medication errors: 3
Insulin dose: 3
Insulin dose: 6
Insulin dose: 9
Insulin dose: 9
Insulin dose: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT B | Certified Medication Technician | Named in medication error findings related to insulin administration and narcotic reconciliation |
| Director of Nursing | Director of Nursing (DON) | Named in narcotic reconciliation and medication administration findings |
| Social Service Director | Social Service Director (SSD) | Interviewed regarding transfer/discharge and bed-hold notification policies |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding verbal notification of hospital transfers |
| Administrator | Facility Administrator | Interviewed regarding transfer/discharge notices, bed-hold policies, narcotic reconciliation, and dietary manager certification |
| Dietary Manager | Dietary Manager (DM) | Named in deficiency for lack of required certification and experience |
| Registered Dietician | Registered Dietician (RD) | Provided guidance on dietary employee certification requirements |
Inspection Report
Plan of Correction
Census: 46
Deficiencies: 7
Date: Apr 3, 2025
Visit Reason
The document is a Plan of Correction submitted by Prairie View Skilled Nursing following a survey conducted from March 31, 2025 to April 3, 2025. It addresses deficiencies cited during the inspection.
Findings
The facility was found deficient in several areas including failure to provide proper notice before transfer or discharge, failure to inform residents and families of bed-hold policies, inadequate trauma-informed care, medication errors exceeding acceptable rates, and insufficient staffing and training in dietary services.
Deficiencies (7)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide written notice of transfer or discharge to residents or their representatives for multiple residents. The facility census was 46.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to inform residents and families of the bed-hold policy at the time of transfer for three residents. The facility census was 46.
F699 Trauma Informed Care: The facility failed to provide trauma-informed care and supportive interventions for a resident diagnosed with PTSD. The facility census was 46.
F755 Pharmacy Services/Procedures/Pharmacist/Records: The facility failed to ensure accurate reconciliation of narcotics for two medication carts and proper documentation for one resident. The facility census was 46.
F759 Free of Medication Error Rates 5 Percent or More: The facility failed to maintain a medication error rate below 5%, with a 10.71% error rate for one resident. The facility census was 46.
F760 Residents are Free of Significant Med Errors: The facility failed to ensure one resident was free from significant medication errors related to insulin administration and blood glucose monitoring. The facility census was 46.
F801 Qualified Dietary Staff: The facility failed to employ a full-time qualified dietary manager and did not ensure the dietary manager completed required certification courses timely. The facility census was 46.
Report Facts
Resident census: 46
Medication error rate: 10.71
Medication error opportunities: 28
Medication error threshold: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Macie Harris | Administrator | Signed Plan of Correction and mentioned in interviews |
| Resident #27 | Resident involved in medication error findings |
Inspection Report
Life Safety
Census: 46
Deficiencies: 2
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related reference documents.
Findings
The facility failed to ensure the proper use of power strips and extension cords, allowing use beyond temporary purposes and multi-plug adapters. This deficiency potentially affected all residents and staff.
Deficiencies (2)
K920 Electrical Equipment - Power cords and extension cords were improperly used beyond temporary purposes and multi-plug adapters were allowed, violating NFPA standards. Observation showed a power splitter in use in the laundry room with multiple chargers plugged in.
A3037 Extension cords and duplex receptacles were not compliant with Underwriters Laboratories (UL) approval or recognized electrical appliance approval standards. Only one appliance was allowed per extension cord, and cords must not be placed under rugs or through doorways.
Report Facts
Facility census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maci Harris | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Life Safety
Census: 34
Deficiencies: 2
Date: Apr 26, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related reference documents.
Findings
The facility failed to maintain high hazardous areas free of penetrations through smoke barriers, with multiple unsealed penetrations observed in mechanical rooms. The emergency preparedness portion of the survey resulted in no deficiencies.
Deficiencies (2)
K321 Hazardous Areas - Enclosure: The facility failed to maintain high hazardous areas free of penetrations through smoke barriers, with multiple unsealed penetrations observed in mechanical rooms. This deficiency potentially affected all residents and staff.
A2008 Hazardous Areas: Hazardous areas must be separated by construction of at least one-hour fire resistant construction or protected by an automatic sprinkler system. This regulation was not met as evidenced by K321.
Report Facts
Facility census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Christian | LVN | Signed the statement of deficiencies and plan of correction |
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 8
Date: Apr 26, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in a skilled nursing facility, including physician orders, wound care, therapy services, catheter care, medication administration, restorative nursing, infection control, and medication labeling and storage.
Findings
The facility failed to obtain physician orders for colostomy care, failed to follow wound care and therapy orders, improperly placed Foley catheter drainage bags, had a medication error rate above 5%, failed to label and store medications properly, and did not maintain proper infection control practices during medication administration, incontinent care, wound care, and blood glucose monitoring.
Deficiencies (8)
Failed to obtain a physician's order for colostomy care for Resident #11.
Failed to follow wound care orders for Resident #17, missing two out of five wound care opportunities.
Failed to follow physician orders for PT, OT, and ST evaluations and treatments for Residents #26 and #30.
Failed to provide appropriate restorative nursing care to Resident #8, missing multiple therapy opportunities.
Failed to ensure proper placement and privacy of Foley catheter drainage bag for Resident #27.
Medication error rate of 8.57% with three errors in medication administration for Residents #1, #5, and #22.
Failed to label insulin pens with opened or expiration dates as required.
Failed to maintain proper infection control practices during medication administration, incontinent care, wound care, and blood glucose monitoring for multiple residents.
Report Facts
Census: 34
Medication error opportunities: 35
Medication errors: 3
Medication error rate: 8.57
Missed restorative therapy opportunities: 15
Missed wound care opportunities: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Named in medication error findings and infection control observations | |
| Assistant Director of Nursing | ADON | Interviewed regarding wound care orders, therapy evaluations, medication administration, and infection control |
| Director of Nursing | DON | Interviewed regarding physician orders, therapy evaluations, medication administration, and infection control |
| Certified Nursing Aide B | CNA | Observed and interviewed regarding incontinent care and infection control |
| Certified Nursing Aide E | CNA | Observed during incontinent care and infection control |
| Restorative Nurse Aide | RNA | Interviewed regarding restorative therapy completion |
| Administrator | Interviewed regarding physician orders, therapy evaluations, and medication administration | |
| Corporate Nurse | Interviewed regarding electronic medical records and therapy orders |
Inspection Report
Plan of Correction
Census: 15
Deficiencies: 9
Date: Oct 22, 2021
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident rights, Medicaid/Medicare coverage notices, comprehensive care plans, and staffing requirements at Bloomfield Living Center.
Findings
The facility was found noncompliant with several requirements including advance directives documentation, timely notification of Medicare non-coverage, comprehensive care plan development and revision, and designation of a full-time Director of Nursing. Deficiencies affected multiple residents and were supported by interviews and record reviews.
Deficiencies (9)
F578: The facility failed to ensure accurate advance directives documentation for five of eight sampled residents. The facility census was 15.
F582: The facility failed to notify residents timely regarding Medicare non-coverage for one of two sampled residents. The facility census was 15.
F656: The facility failed to develop and implement comprehensive care plans with measurable goals and timeframes for four of eight sampled residents. The facility census was 15.
F657: The facility failed to ensure timely care plan development and revision involving interdisciplinary teams and resident representatives for four of eight sampled residents. The facility census was 15.
F727: The facility failed to designate a full-time Director of Nursing as required. The facility census was 15.
A4036: The facility failed to employ a full-time Director of Nursing responsible for quality and supervision of patient care. Refer to F727.
A8008: The facility failed to fully inform residents or their representatives of services and charges related to Alzheimer's special care. Refer to F582.
A8010: The facility failed to comply with advance directive requirements including informing residents and placing directives in medical records. Refer to F578.
A8013: The facility failed to ensure residents were afforded the opportunity to participate in planning care and refuse treatment with informed consent. Refer to F657.
Report Facts
Facility census: 15
Residents sampled: 8
Residents affected: 5
Residents affected: 4
Residents affected: 1
Inspection Report
Life Safety
Census: 15
Deficiencies: 2
Date: Oct 22, 2021
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related reference documents.
Findings
The facility failed to maintain functioning exit signage, specifically the exit sign at the service entrance door did not illuminate when tested. This deficiency potentially affected all residents and staff.
Deficiencies (2)
K293 Exit signage did not illuminate at the service entrance door, failing to meet NFPA 101, 2012 requirements for means of egress illumination.
A2047 Facilities did not place exit signs with legible block letters at required exits, violating 19 CSR 30-85.022(22) Exit Sign Requirements.
Report Facts
Facility census: 15
Inspection Report
Annual Inspection
Census: 15
Deficiencies: 5
Date: Oct 22, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, staffing, and notification procedures in a skilled nursing facility.
Findings
The facility was found deficient in ensuring accurate advance directives for residents, timely notification of Medicare non-coverage, complete and updated individualized care plans reflecting residents' elected code status, involvement of residents and families in care planning, and designation of a full-time registered nurse as Director of Nursing.
Deficiencies (5)
Failed to ensure the accuracy of advance directives regarding resuscitation status for five residents.
Failed to complete and notify in the proper time frame for the Notice of Medicare Non-Coverage for one resident.
Failed to ensure residents had complete, accurate, and individualized care plans addressing elected code status with measurable goals and interventions.
Failed to ensure resident and/or family involvement in the revision or updating of care plans.
Failed to designate a Registered Nurse to serve as Director of Nursing on a full-time basis.
Report Facts
Residents affected: 5
Residents affected: 1
Residents affected: 4
Residents affected: 4
Facility census: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding care plan process, notification expectations, and staffing | |
| Social Services/Activity Director (SS/AD) | Interviewed regarding Medicare Non-Coverage notification and care plan process | |
| RN A | Registered Nurse | Interviewed regarding lack of full-time Director of Nursing |
| MDS Coordinator | Responsible for care plan completion and updates; interviewed regarding resident/family involvement |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 22, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Dec 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: May 19, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 5/19/20 to assess compliance with CMS and CDC guidelines.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and emergency preparedness regulations.
Inspection Report
Annual Inspection
Census: 26
Deficiencies: 8
Date: Oct 16, 2019
Visit Reason
The inspection was conducted as an annual survey of Bloomfield Living Center to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including mail delivery policies, enteral feeding procedures, nurse aide training, drug labeling and storage, infection control, and employee screening for communicable diseases. Several deficiencies were cited with varying severity levels.
Deficiencies (8)
F576: The facility failed to provide mail delivery on Saturdays for one resident, potentially affecting all residents. Mail collected on Saturdays is held until Monday, delaying delivery.
F693: The facility failed to ensure proper procedures for checking placement of a gastrostomy tube (G-tube) for one resident, risking aspiration and other complications.
F730: The facility failed to conduct annual nurse aide training on dementia care for two nurse aides. No policy on nurse aide training requirements was provided.
F761: The facility failed to date multi-dose vials when opened, risking medication safety. No policy on dating opened medication vials was provided.
F880: The facility failed to maintain an adequate infection prevention and control program to prevent spread of infection, including hand hygiene and glove use policies. No policy was provided.
A4029: The facility failed to implement policies to screen employees for communicable diseases, including tuberculosis (TB), for four new employees. This posed a risk of TB exposure to residents.
A4063: The facility failed to store medications at appropriate temperatures and in locked compartments as required. Refer to F761 for related medication storage issues.
A4074: The facility failed to provide personal attention and nursing care consistent with residents' conditions and accepted nursing practice. Refer to F693 and F880 for related deficiencies.
Report Facts
Facility census: 26
Number of nurse aides missing dementia training: 2
Number of sampled residents for infection control: 12
Number of new employees missing TB screening: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee C | New employee not screened for tuberculosis | |
| Licensed Practical Nurse B | Licensed Practical Nurse | Observed medication administration and failure to date medication vials |
| Certified Nursing Assistant D | Certified Nursing Assistant | Did not attend annual dementia training |
| Certified Nursing Assistant E | Certified Nursing Assistant | Did not attend annual dementia training |
Inspection Report
Life Safety
Census: 26
Deficiencies: 7
Date: Oct 16, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code, including emergency preparedness, fire safety, emergency lighting, smoke barriers, and fire drills.
Findings
The facility failed to maintain adequate emergency lighting, maintain smoke barriers free of penetrations, and perform fire drills in a non-predictable pattern. These deficiencies potentially affected all residents and staff.
Deficiencies (7)
K281 Emergency lighting was not maintained to provide adequate illumination of exit paths, including the smoking patio and patio exit lights which were nonfunctional.
K321 The facility failed to maintain hazardous areas free of smoke penetrations, including seven ceiling penetrations in the utility room not sealed with fire rated sealant.
K372 Smoke barriers were not maintained free of penetrations, including a half inch hole in the smoke wall by the dining room not sealed with fire retardant sealant.
K712 The facility failed to perform fire drills in a non-predictable pattern, with drills conducted only on the last days of the month and third shift not covered.
A2008 Hazardous areas were not separated by construction of at least one-hour fire resistant construction as required.
A2050 Emergency lighting was not sufficient to provide safety for residents and others using exits, stairways, and corridors, lacking proper emergency lighting system testing and documentation.
A2054 Smoke section walls and doors were not maintained as one-hour fire-rated continuous barriers, with doors not closing automatically upon fire alarm activation.
Report Facts
Facility census: 26
Facility census: 28
Inspection Report
Plan of Correction
Census: 23
Deficiencies: 7
Date: Nov 8, 2018
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident transfer/discharge notices, bed hold policies, baseline care plans, and enteral nutrition management at Bloomfield Living Center.
Findings
The facility failed to notify residents or their representatives in writing of transfers to hospitals and bed hold policies. The baseline care plan was not developed or implemented within 48 hours for one resident. The facility staff failed to properly check placement and residual of gastrostomy tubes for one resident.
Deficiencies (7)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify the resident or representative in writing of a facility-initiated transfer to the hospital for one resident.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to inform the resident and family or legal representative of their bed hold policy at the time of transfer to the hospital for one resident.
F655 Baseline Care Plan: The facility failed to develop and implement a baseline care plan consistent with the resident's specific conditions, needs, and risks within 48 hours of admission for one resident.
F693 Tube Feeding Management/Restore Eating Skills: The facility staff failed to check placement and residual of a gastrostomy tube for one resident, risking complications such as aspiration pneumonia and metabolic abnormalities.
A4053 Written Orders; Restraints: No medication, treatment, or diet shall be given without a written order from a person lawfully authorized to prescribe such and the order shall be followed.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice.
A8008 Informed Services/Charges - Alzheimer's Disclosure: Residents and their representatives must be fully informed in writing of services available and charges for Alzheimer's special care program or unit.
Report Facts
Facility census: 23
Days after admission for baseline care plan completion: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding notification of transfer and bed hold policy; stated facility did not inform resident or representative in writing |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Observed preparing and administering medications via gastrostomy tube; failed to check tube placement and residual |
| Quality Assurance nurse | Quality Assurance (QA) nurse | Interviewed about medication administration and tube placement checks |
Inspection Report
Life Safety
Census: 23
Deficiencies: 21
Date: Nov 8, 2018
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with fire safety and emergency preparedness regulations at Bloomfield Living Center.
Findings
The facility failed to meet multiple life safety code requirements including exit egress door locking arrangements, emergency lighting, fire sprinkler system maintenance, fire alarm system repairs, kitchen hood filter maintenance, fire extinguisher inspections, corridor door latching, smoke barrier walls, smoking regulations, electrical receptacle testing, and oxygen storage safety. The facility census was 23 at the time of inspection.
Deficiencies (21)
K222 Egress Doors: The facility failed to maintain exit egress doors free from impediments preventing opening during an emergency. Several doors did not release when tested.
K281 Illumination of Means of Egress: The facility failed to maintain the emergency lighting system, including switches that could manually override lighting, affecting safety during a fire.
K321 Hazardous Areas - Enclosure: The facility failed to maintain fire-rated barriers in highly hazardous areas, including fire sprinkler riser room deficiencies.
K324 Cooking Facilities: The facility failed to maintain kitchen range hood filters free of grease buildup, risking fire hazards.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to make timely repairs to the fire alarm system, including smoke detectors that did not meet manufacturer standards.
K355 Portable Fire Extinguishers: The facility failed to maintain monthly fire extinguisher inspections, with several extinguishers missing required checks.
K361 Corridors - Areas Open to Corridor: The facility failed to maintain corridor doors free from impediments preventing closing and latching, risking fire spread.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: The facility failed to maintain complete smoke barrier walls, with penetrations and unsealed cable wiring.
K741 Smoking Regulations: The facility failed to maintain smoking areas in accordance with NFPA regulations, including proper ashtray disposal and signage.
K912 Electrical Systems - Receptacles: The facility failed to provide adequate testing and maintenance of resident room receptacles, risking electrical hazards.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to prohibit use of adapters, power strips, and extension cords beyond temporary installation in patient care areas.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain safe storage of oxygen cylinders, including proper signage and combustible material clearance.
A1036 Oxygen Storage Room: The facility failed to maintain an oxygen storage room with required one-hour fire-rated construction and proper ventilation.
A1125 Electrical System Complies With Code: The facility failed to comply with electrical code requirements for maintenance and operation.
A2016 Fire Extinguisher UL/FM Monthly Check: The facility failed to maintain monthly fire extinguisher inspections as required by NFPA 10.
A2041 Door Locks: The facility failed to maintain door locks that can be opened from the inside by turning the knob or operating a simple device.
A2046 Corridor Requirements: The facility failed to maintain corridors free of obstruction and doors that do not swing into the corridor.
A2050 Emergency Lighting: The facility failed to maintain emergency lighting of sufficient intensity for safety of residents and staff.
A2054 Smoke Section Walls/Doors: The facility failed to maintain smoke sections separated by one-hour fire-rated walls and self-closing doors.
A2055 Door Devices: The facility failed to maintain self-closing devices on doors providing separation between floors and electromagnetic hold-open devices.
A2057 Ashtrays Noncombustibles/Safe/Disposal: The facility failed to provide ashtrays of noncombustible material and proper disposal of contents.
Report Facts
Facility census: 23
Smoke detectors failing standards: 36
Fire Control Panel: 1
Smoke detectors: 40
Heat detectors: 21
Days delay for fire alarm repairs: 140
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