Prairie Maison

Inspectors wroteBased on interview, and record review, the facility did not ensure to report an allegation of verbal abuse to the State Agency (SA) within five working days for one resident of six sampled residents (Resident (R) 4) reviewed for abuse in a total sample of eight.

Inspectors wroteBased on interviews and record review, the facility did not ensure a thorough investigation was completed for allegations of verbal and physical abuse for three residents (Residents (R)4, R5, and R6) of four sampled residents reviewed for abuse in a total sample of eight. This failure placed residents at risk of further abuse and lack of safety. Allegations of abuse were not thoroughly investigated for R4, R5 or R6.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to notify the State Mental Health Authority of a significant change in status for one resident (Resident (R)1) in a total sample of eight who was previously identified as having a serious mental illness.

Inspectors wroteBased on interview, record review and review of the facility policy, the facility failed to ensure that appropriate treatment and services were provided to correct or assist 1 of 8 sampled residents (R1) in achieving his highest practicable mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with a physician when needing to alter treatment for 1 of 9 (R32) residents reviewed for physician notification. R32 experienced severe weight loss of 10 lbs. over 7 days from 7/8/25 to 7/15/25, indicating a weight loss of 8.91%. The facility did not call the on-call physician to allow for alteration of treatment if the physician deemed it necessary. This is evidenced by: The facility policy titled, Physician Notification of Resident Change of Condition, dated 11/2024, states, in part: . 1. Immediate Notification: the physician should be informated [sic] at the time the event occurs. [NAME] use INTERACT 3.0 CHANGE OF CONDITION FILE CARDS AND CARE PATH CARDS to guide immediate criteria. 2. Non-immediate Notification: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the environment was free of accident hazards for 1 of 3 residents (R46) reviewed for falls. R46 has had multiple falls since admission to the facility. The root cause was not documented for each fall. R46's care plan was not updated after each fall to include interventions to prevent future falls. R46's care plan contained an intervention that had gotten discontinued but remained on the care plan. Evidenced by: The facility's fall policy titled, Fall Report and Assessment dated 11/24 states, in part: It is the policy of this facility to complete a Risk Management and root cause analysis whenever a resident has fallen. Provide documentation of each fall and interventions to prevent future falls. [...]

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 1Based on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 (R16) supplemented resident. R16 was treated with an antibiotic for a UTI (Urinary Tract Infection) without appropriate indications for use. Evidenced by:The facility policy titled, Antibiotic Stewardship Policy, reviewed 1/2025, states, in part: .[Corporation Name] antibiotic stewardship program promotes the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and reduced antibiotic resistance. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 5 of 6 residents (R1, R2, R10, R11 and R12) reviewed for abuse. Facility did not report an allegation of R1 watching child pornography on his cell phone and offering to show the child pornography to R2 to State Survey Agency or Law Enforcement. R10 reported hearing a staff member yelling at another resident and the facility did not report the incident to the state agency. R11 reported that a staff member told her not to use her call light so much and the facility did not report the incident to the state agency. [...]

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for 5 of 6 residents (R1, R2, R10, R11, and R12) reviewed for abuse. Facility did not fully investigate an allegation of R1 watching child pornography. R10 reported hearing a staff member yelling at another resident. The facility did not fully investigate the incident and put protections in place. R11 reported that a staff member told her not to use her call light so much. The facility did not fully investigate the incident. R12 reported that the nurse would not give her a pain pill. The facility did not fully investigate the incident. Evidenced by: The facility's Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigation policy, dated 1/25, includes, in part, the following: Reporting Allegations to the Administrator and Authorities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place to assess for risk of entrapment between the mattress and side rail, failed to ensure other alternatives were tried prior to installing/utilizing side rails for 16 of 22 residents with side rails/enabler bars with a standard mattress (R3, R5, R6, R7, R8, R10, R12, R13, R14, R16, R17, R18, R19, R20, R22, and R23) and failed to identify and recognize that the use of side rails with an air mattress increases the risk for entrapment for 6 of 22 (R2, R9, R11, R15, R21, and R24) residents who use an air mattress and side rails/enabler bars. R2's bed was equipped with A Pressure Guard APM - Bariatric Solutions alternating air mattress as well as two half bed rails. On 2/9/25, R2 was found to have a large bruise on the right side of his neck. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the residents environment remained as free of accidents and hazards as possible for 1 of 1 resident's (R10) reviewed for accidents and supervision. R10 sustained first and second degree burns on her leg when she spilled hot coffee on herself. This is evidenced by: The facility's policy titled Food Safety: Preventing Burns, dated 2023, states in part: Hot food and beverages will be served at a safe temperature that prevents burns. Staff will monitor hot food and beverage temperatures at the point of service. Hot beverages will be produced at 160 degrees to 185 degrees, the optimum temperature for patient/resident satisfaction. Hot beverages will be handled carefully during food deliver and meal set-up in an attempt to avoid spills that could cause burns. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received adequate supervision and assistive devices to prevent accidents from occurring for 2 of 4 residents (R) reviewed for falls (R38 and R11). R38 has a known history of falls, including one with a fracture. The facility did not identify the root cause for R38's falls or develop/implement a care plan with interventions to prevent falls. R38 fell on 5/31/24 and sustained a fracture of her left hip. The facility staff did not follow R11's care plan related to fall interventions after R11 sustained a pelvic fracture. Evidenced by: The facility's policy titled, Fall Prevention Protocol dated 6/22/21, updated 10/25/21, states in part: [...]

Inspectors wroteBased on interview and record review the facility did not develop a comprehensive person-centered care plan for 5 of 5 residents (R19, R38, R30, R28, and R16) reviewed for unnecessary medications. R19 does not have a comprehensive person-centered care plan for the use of an antipsychotic medication and anti-seizure medication. R38 does not have a resident specific care plan for the use of an antidepressant and use of Melatonin as a sleep aid. R30's care plan does not include individualized targeted behaviors and non-pharmacological interventions for the use of a psychotropic medication. R30 does not have a care plan for insomnia. R28 does not have care plans that include his psychotropic medications and what they are being used for. R16's care plan does not include individualized targeted behaviors and non-pharmacological interventions for the use of an antidepressant medication. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 5 of 5 Residents (R28, R16, R30, R38, and R19) reviewed for unnecessary medications. R16, R30, R19, and R38 were prescribed psychotropic medications without individualized behavior monitoring or non-pharmacological approaches/interventions utilized. R16, R30, and R38 receive medication for insomnia and have no sleep assessment/sleep monitoring documented. R28 does not have any individualized targeted behaviors for his use of psychotropic medications. This is evidenced by: The facility's undated policy titled Psychotropic Medication Use, states in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident's care plan included interventions to prevent accidents for 1 of 3 Residents reviewed for falls (R3). R3 has history of falls; her care plan does not reflect fall interventions put into place following falls that occurred. This is evidenced by: The facility policy titled, Fall Report and Assessment Policy and Procedure, updated 10/25/21, states in part . Policy: It is the policy of this facility to complete a fall huddle and root cause analysis whenever a resident has fallen. Purpose: To provide documentation of each fall and interventions to prevent future falls. Procedure: 1. The nurse assigned to that resident is responsible for completion of the Fall Report and Assessment Form when there is a fall. 2. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to report a resident abuse allegation timely to the Administrator and to the state agency for 1 (Resident 98) of 3 residents reviewed for resident abuse. On 01/24/2023, Resident 98 alleged the overnight staff were rough while providing care and reported it to the nursing staff; however, the nursing staff did not report the allegation to the Administrator until 1/26/23 when the allegation was then reported to the state agency.