French Prairie Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure food was palatable and served at an appropriate temperature for 1 of 1 lunch meal service reviewed for dietary concerns. This placed residents at risk for unpalatable meals.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure tube feeding supplies were provided for 1 of 3 sampled residents (# 8) reviewed for nutrition. This placed residents at risk for poor nutrition and a delay in enteral feeding.

Inspectors wroteBased on interview and record review it was determined the facility failed to administer medications according to physician orders for 1 of 3 sampled residents (#3) reviewed for medications. This placed residents at risk for not receiving medications as ordered and potential side effects.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure meals were palatable for 1 of 1 kitchen observed for food services. This placed residents at risk for receiving food that was unpalatable.

Inspectors wroteBased on observation and interview, it was determined the facility failed to provide residents with alternative meals for 1 of 1 kitchen reviewed for food service. This placed residents at risk for not receiving nourishing meals.

Inspectors wroteBased on interview and record review it was determined the facility failed to report an allegation of abuse to the State Agency within the required timeframe for 1 of 4 sampled residents (#9) reviewed for abuse. This placed residents at risk for abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to thoroughly investigate an allegation of abuse for 1 of 4 sampled residents (#9) reviewed for abuse. This placed residents at risk for physical abuse.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure sufficient nursing staff were available to meet resident needs for 1 of 1 facility reviewed for staffing. This placed residents at risk for lack of timely assistance and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure facility administration used the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident related to lack of sufficient staffing, lack of a facility assessment, and significant medication errors for 1 of 1 facility reviewed for effective administration.1. Observations on 9/24/25 and 9/25/25 revealed delayed responses to call lights, staff appeared and reported to be rushed, and residents were waiting for assistance from staff and appeared frustrated from the lack of timely assistance. Facility documentation including grievances and Direct Care Staff Daily Reports revealed chronic concerns spread across multiple months related to insufficient staffing, which resulted in delayed assistance or assistance not provided at all. [...]

Inspectors wroteBased on interview and record review, it was determined the facility failed to conduct and complete a comprehensive facility assessment to care for its residents competently during day-to-day operations. This placed residents at risk for unidentified and unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to notify a resident's responsible party of a significant change of condition for 1 of 3 sampled residents (#3) reviewed for medication. This placed residents at risk for their responsible party not being informed of the resident's status.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#3) reviewed for medication. This placed residents at risk for reduced efficacy of medications.

Inspectors wroteBased on interview and record review it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for required staff postings. This placed residents and the public at risk for incomplete and inaccurate staffing information.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to identify, assess, treat, and implement contact precautions for residents with symptoms of clostridioides difficile (c-diff, a bacterium that can cause severe diarrhea and inflammation of the colon) and failed to utilize appropriate contact precautions to prevent the spread of c-diff for 4 of 4 sampled residents (#s 31, 32, 40 and 109) with diagnoses of c-diff. This failure, determined to be an Immediate Jeopardy situation, placed all residents at risk for exposure to c-diff, which is highly contagious and requires treatment including the use of a toxic anti-infective medication with potential to cause serious side effects.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 3 of 3 halls reviewed for staffing. This placed residents at risk for delayed and unmet care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a registered nurse was available for at least eight consecutive hours, seven days a week for 13 of 91 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including nursing assessments.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 4 of 4 sampled CNA staff (#s 22, 28, 29, and 30) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff.

Inspectors wroteBased on interview and record review it was determined the facility failed to obtain informed consent prior to administration of a psychotropic medication for 1 of 5 sampled residents (#34) reviewed for unnecessary medications. This placed residents at risk for being uninformed of the risks and benefits of their medications.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were assessed for self-administration of medications for 1 of 1 sampled resident (#104) reviewed for medication self-administration. This placed residents at risk for adverse outcomes related to unsafe self-administration of medication.

Inspectors wroteBased on interview and record review it was determined the facility failed to administer bowel care medication and ensure physician orders related to bowel care were followed for 1 of 5 sampled residents (#4) reviewed for unnecessary medications. This placed residents at risk for adverse outcomes related to constipation.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received vision treatment and services for 1 of 2 sampled residents (#27) reviewed for vision. This placed residents at risk for vision loss.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received required dialysis care including post-dialysis assessments for 1 of 1 sampled resident (#28) reviewed for dialysis. This placed residents at risk for dialysis complications.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide timely pharmaceutical services for 1 of 2 sampled residents (#102) reviewed for pain. This placed residents at risk for untreated medical needs.

Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to ensure a medication error rate of less than five percent. There were 2 errors out of 26 medication administration opportunities resulting in a 7.69% error rate. This placed residents at risk for reduced medication efficacy and feeding tube complications.

Inspectors wroteBased on interview and record review it was determined the facility failed to obtain lab samples for 1 of 5 sampled residents (#21) reviewed for unnecessary medications. This placed residents at risk for lack of treatment.

Inspectors wroteBased on interview and record review it was determined the facility failed to notify a resident's responsible party in writing prior to a change in room of the reason for the room change for 1 of 3 sampled residents (#4) reviewed for resident rights. This placed residents at risk for potential adjustment difficulties and delayed responsible party notification related to changes in room location.

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from deprivation of goods and services for 2 of 3 sampled residents (#s 17 and 18) reviewed for abuse and neglect. This placed residents at risk for abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure Staff 8 (LPN) adhered to professional standards of practice related to deprivation of goods and services for 2 of 3 sampled residents (#s 17 and 18) reviewed for abuse and neglect. This placed residents at risk for abuse.

Inspectors wroteBased on interview and record review, it was determined the facility failed to assess and monitor pressure ulcers for 3 of 6 sampled residents (#s 13, 15 and 22) reviewed for pressure ulcers. This placed residents at risk for worsening wounds.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the resident environment was free from accident hazards for 1 of 1 sampled resident (#199) reviewed for accidental injury. This failure, determined to be an Immediate Jeopardy (IJ) situation, resulted in Resident 199 sustaining third degree burns requiring acute care intervention when her/his foot sustained prolonged contact with an electric baseboard heater.

Inspectors wroteBased on interview and record review it was determined the facility failed to monitor CBGs for a resident with diabetes for 1 of 1 sampled resident (#32) reviewed for medications. This failure resulted in Resident 32's unmonitored blood glucose which required treatment at the hospital.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide sufficient nursing staff to ensure residents attained their highest practicable psychosocial well-being for 3 of 3 halls reviewed for staffing. This placed residents at risk for delayed care and unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to use the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week for 10 of 97 days reviewed for RN staffing coverage. This placed residents at risk for lack of RN oversight including resident assessment, care and services.

Inspectors wroteBased on interview and record review it was determined Staff 28 (Former DNS) falsified resident records for 20 of 20 sampled residents (#s 1, 7, 15, 21, 22, 23, 24, 26, 30, 31, 36, 40, 51, 57, 59, 60, 61, 62, 198 and 202) reviewed for false documentation. This placed residents at risk for inaccurate medical records, missed medications and a delay in treatment.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide ADL care to 4 of 4 sampled residents (#s 11, 27, 33 and 41) reviewed for ADLs. This placed residents at risk for unmet needs and loss of dignity.

Inspectors wroteBased on interview and record review it was determined the facility failed to assess and treat skin conditions and administer medications as ordered for 8 of 12 sampled residents (#s 4, 9, 11, 25, 41, 43 and 54) reviewed for skin and medications. This placed residents at risk for worsening skin conditions, adverse medication side effects, constipation.

Inspectors wrote2. Resident 15 admitted to the facility in 5/2023 with diagnoses including neuromuscular dysfunction of the bladder. The 5/17/23 Urinary Care Plan revealed the resident had a history of urine retention and frequent UTIs. Staff were to check the tubing for kinks every shift. The current Kardex (CNA care plan) instructed staff to check tubing for kinks every shift. The Point of Care documentation revealed staff documented the resident utilized a urinary catheter and recorded how much urine output there was each shift. The November 2023 TARs revealed an order to change the urinary catheter monthly. Review of Resident 15's medical record revealed no evidence catheter care (cleansing of the area) was completed. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily reports were accurate for 36 of 41 days reviewed for staffing. This placed residents at risk for inaccurate staffing information.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained for 1 of 3 medication storage refrigerators reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy.

Inspectors wroteBased on observation and interview it was determined the facility failed to provide palatable and appealing food for 4 of 5 sampled residents (#s 16, 18, 20 and 247) reviewed for food. This placed residents at risk for weight loss.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident records were accurately documented for 20 of 20 sampled residents (#s 1, 7, 15, 21, 22, 23, 24, 26, 30, 31, 36, 40, 51, 57, 59, 60, 61, 62, 198 and 202) reviewed for false documentation. This placed residents at risk for inaccurate medical records.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete a Baseline Care Plan within 48 hours of admission for 3 of 9 sampled residents (#s 41, 43 and 199) reviewed for medications, catheter care and hospice. This placed residents at risk for a lack of care and services.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete a comprehensive recapitulation of stay and a final summary of the resident's status upon discharge for 1 of 2 sampled residents (#55) reviewed for discharge. This placed residents at risk for an unsafe discharge.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow the care plan which resulted in a fall for 1 of 1 sampled resident (#55) reviewed for falls. This placed residents at risk for falls.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide care and services for a central venous port for 1 of 1 sampled resident reviewed for IV (Intravenous) medications. This placed residents at risk for worsening infections and hospitalization.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders related to oxygen administration and maintain oxygen concentrators for 2 of 2 sampled residents (#s 9 and 20) reviewed for oxygen therapy. This placed residents at risk for difficulty breathing.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure dialysis treatment and care was in place including monitoring and communication with the dialysis provider for 1 of 1 sampled resident (#18) reviewed for dialysis (a procedure to remove waste products from the blood when the kidneys stop working.) This placed residents at risk for dialysis complications.

Inspectors wroteBased on interview and record review it was determined the facility failed to obtain medications timely to ensure the provision of routine medications for 2 of 6 sampled residents (#s 247 and 347) reviewed for medications. This placed residents at risk for not receiving prescribed medications.

Inspectors wroteBased on interview and record review it was determined the facility failed to respond to pharmacy recommendations in a timely manner for 1 of 2 sampled residents (#21) reviewed for medications. This placed residents at risk for potential adverse consequences related to medications.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a risk versus benefits for the use of the psychotropic medication in the form of a signed informed consent was obtained for 1 of 5 sampled residents (#397) reviewed for unnecessary psychotropic medications. This placed residents at risk to receive unnecessary medications and/or adverse side effects.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 1 of 1 sampled resident (#52) reviewed for medication and medication treatments. This placed residents at risk for medical complications.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete laboratory testing as ordered for 1 of 1 sampled resident (#25) reviewed for lab orders. This placed residents at risk for worsening conditions.

Inspectors wroteBased on interview and record review it was determined the facility failed to comprehensively investigate resident-to-resident verbal and aggressive incidents for 3 of 3 sampled residents (#s 3, 4 and 7) who were reviewed for abuse. This placed residents at risk for continued abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the resident received care in accordance with professional standards of practice for 1 of 3 sampled residents (#1) reviewed for safety. This placed residents at risk for unknown injury hazards.

Inspectors wroteBased on interview and record review it was determined the facility failed to obtain copies of and provide assistance to residents who expressed interest in formulating an advanced directive for 4 of 4 sampled residents (#s 3, 25, 28 and 108) reviewed for advanced directives. This placed residents at risk of not having their healthcare decisions honored.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assess a resident's ability to self-administer medications for 1 of 6 sampled residents (#50) reviewed for medication administration. This placed residents at risk for unsafe medication administration.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide care and services in relation to bathing for 2 of 4 sampled resident (#s 25 and 33) reviewed for ADLs and choices. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to initiate treatment and monitoring when an area of skin impairment was identified for 1 of 1 sampled resident (#108) reviewed for non-pressure skin conditions. This placed residents at risk for lack of treatment and worsening of wounds.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide necessary treatment and services to prevent the development of an avoidable pressure ulcer for 1 of 3 sampled residents (#50) reviewed for pressure ulcers. This placed residents at risk for worsening wounds.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to identify the need for diabetic foot care for 2 of 2 sampled residents (#s 50 and 108) reviewed for foot care. This placed residents at risk for complications associated with diabetes.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a medicated powder was not left at the bedside of a cognitively impaired resident for 1 of 4 sampled residents (#34) reviewed for accidents. This placed residents at risk for the inappropriate consumption of an antifungal powder medication not meant to be orally ingested.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent. The facility's medication administration error rate was 7%. This placed residents at risk for adverse medication consequences.