Prairie Meadows Rehabilitation and Healthcare Cent

Inspectors wroteBased on interview, and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 17 residents (Resident #3) reviewed for assessments: The facility failed to ensure Resident #3's Annual MDS dated [DATE] indicated she was PASRR positive. These failures could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 17 residents (Residents #17) reviewed for infection control, in that: The facility failed to ensure CNA A sanitized his hands and changed gloves between residents and while providing incontinent care for Resident #17. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 4 residents reviewed for quality of care. The facility failed to accurately perform a head-to-toe-readmission assessment of Resident #1 on 12/11/25 and did not identify and assess a peripheral IV catheter located on the resident's chest until 12/14/25. This failure placed the resident at risk for complications including infection, infiltration (leakage of IV fluid or medication into the surrounding tissue instead of the vein, which can cause swelling, pain, and tissue damage), and dislodgement (movement or accidental removal of the IV catheter from the vein, which can cause bleeding, injury, or infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 4 residents (Resident #2, and Resident #4) reviewed for incontinent care: 1. The facility failed to ensure CNA A wiped between Resident #2's labia folds during incontinent care. 2. The facility failed to ensure Resident #2's catheter bag was not touching the floor during incontinent care. 3. The facility failed to ensure Resident #4's catheter bag was not touching the floor. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 4 residents (Residents #1) reviewed for medical records. The facility failed to ensure Resident #1's medication administration report did not contain blanks. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 Residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a care plan that addressed Resident #1's wound on his left buttock identified as a stage 3 pressure ulcer (a bed sore which is an open wound that extends through the skin down into the fatty tissue, appearing as a deep crater but the bone, tendon or muscle are not exposed) by the Wound Care NP A on 11/20/2025 until 12/31/2025, 41 days later; [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that a resident received care, consistent with professional stands of practice, to prevent pressure ulcers for 1 of 3 residents (Resident #95) reviewed for Pressure Ulcers. The facility failed to implement the Wound Care NP recommendations for 8 days when Resident #1 was identified with a stage 3 pressure injury to the left buttock from 11/20/2025 to 11/28/2025. Resident #1 refused wound care 22 times from 11/28/2025 to 12/24/2025, and refused further assessment of the wound from the Wound Care NP. On 12/24/2025, Resident #1 had maggots in his wound and the wound had increased in size from 4 cm x 5 cm x 0.2 cm on 12/10/2025 to 6 cm x 3.5 cm x 2 cm on 12/24/2025. An IJ situation was identified on 01/02/2026. The IJ template was provided to the facility on [DATE] at 09:13 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that it was free of pests and rodents for 1 of 1 residents (Resident #1) reviewed for pest control program. The facility failed to ensure Resident #1 was not found with maggots in his left stage 3 buttock wound on 12/24/25. An IJ was identified on 1/1/26. The IJ template was provided to the facility on 1/1/26 at 8:25 p.m. While the IJ was removed on 1/3/26 at 7:24 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility's need to monitor the implementation and effectiveness of its Plan of Removal. The failure could place residents with wounds at risk for infection or infestations from pests.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure personal privacy for 1 of 6 residents (Resident #8) reviewed for privacy, in that: LVN J provided tracheostomy care for Resident #8 with the resident room door open, curtain separating A and B bed open and window blinds open. This failure could affect residents receiving tracheotomy care by resulting in loss of dignity and low self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #8) reviewed for infection control in that: LVN J did not wear a gown when providing direct care to Resident #8 who had a tracheotomy and was on enhanced barrier precautions (EBP). This failure could affect residents on enhanced barrier precautions and place them at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. 1. The facility failed to ensure a case of cinnamon rolls was properly sealed in the reach-in freezer. 2. The facility failed to ensure the interior of the ice machine in the kitchen was free of dirt and debris. 3. The facility failed to ensure opened bags of graham cracker crumbs, cookie pieces, cake mix and frosting mix were sealed in the dry storage room [ROOM NUMBER]. The facility failed to ensure opened bag of snacks and cookies were sealed in the kitchen. 5. The facility failed to record the chemical sanitizing solution concentrations of the dish machine on the log sheet in the dish room. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that for a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 12 residents (Residents #49 and #52) reviewed for indwelling catheters and perineal/incontinent care, in that: The facility failed to ensure Resident #49's and Resident #52's indwelling catheter tubing were not attached to leg straps to prevent pulling or tugging on the urethra on 08/26/25. These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections due to improper care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3 the residents (Resident # 49) reviewed for oxygen in that: The facility failed on 8/26/2025to ensure that Resident #49's nebulizer tubing was bagged. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that in accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 of 3 residents (Resident #58) reviewed for medication storage in that: The facility failed on 8/26/25 to ensure medications were not left on Resident #58's bedside table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered.

Inspectors wroteBased on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 2 of 3 Dumpsters (Dumpsters #1 and #3) reviewed for garbage and refuse disposal. The facility failed to ensure Dumpster #1 had a drainage plug and Dumpster #3 was free of gaps. These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable state laws for 1 of 4 (LPN A) staff reviewed for staff qualifications. The facility failed to ensure LPN A's nursing license was not expired between [DATE] and [DATE]. This failure could place residents at risk for not receiving nursing services by a licensed nurse.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for clinical records. The facility failed to ensure Resident #1's weights were documented in his medical record for 4 of 5 weeks (weeks of 03/13/2025, 03/20/2025, 03/27/2025, and 04/03/2025) reviewed. This failure could place residents at risk of not receiving the care and services needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents and supervision, in that: The facility failed to provide adequate supervision and assistive devices to prevent accidents when Resident #1 was confused and required assistance to ambulate. A fall mat was not in place and the bed was not in a low position, and Resident #1 fell out of bed and sustained a left femoral neck hip fracture. An IJ was identified on 11/26/2024. The IJ template was provided to the facility on [DATE] at 4:50 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation was made for 1 (Resident #1) of 6 residents reviewed for reporting of alleged violations, in that: The facility failed to report to the state agency, an incident of neglect regarding Resident #1, after he had an unwitnessed fall in his room with a possible injury to his hip that occurred on 11/01/2024. The unwitnessed fall later revealed through CT scan (a scan to create cross sectional images of organs, bones, and other tissues), Resident #1 had a left femoral hip fracture, and it was not reported to the state as of 11/06/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post daily information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 2 days (11/05/2024 and 11/06/2024) of 3 days reviewed. The facility did not post the required current nurse staffing information for 11/05/2024 and 11/06/2024. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to reside in a safe, clean, comfortable, and homelike environment for 4 of 23 residents (Residents #43, #48, #45, and #31) reviewed for a safe, clean, and comfortable environment, in that: 1. Resident #43's bathroom floor molding which measured approximately 1.5 feet by 4 inches was removed from the wall. 2. Resident #48's bathroom ceiling vent which measured approximately 6x4 inches was rusty and covered with dirt particles. 3. Resident #45's bathroom ceiling vent which measured approximately 6x4 inches and the bedroom ceiling vent which measured approximately 1.5 feet by 4 inches were covered with dust and dirt particles. 4. Resident #31's toilet was running and would not stop on it's own. These deficient practices could lead to diminished quality of life and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements, in that: The DM did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation, in that: 1. There was a bag of strawberries in the reach-in freezer without a label indicating a use-by date. 2. There was a loaf of bread in the dry storage room past its use-by date. 3. There were three packages of tortillas in the dry storage room past their use-by date. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 2 of 3 the residents (Residents #16 and #37) reviewed for respiratory care, in that: The nebulizer tubing of Residents #16 and #37 was on their bedside tables unbagged and undated. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 1 of 5 residents (Resident #16) reviewed for medication storage, in that: The facility failed to ensure medications were not left on Resident #16's bedside table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to ensure the freezer in the main kitchen had a thermometer; the food in the refrigerator was stored properly and not used past 3 days from storing it; the kitchen equipment was clean; the pans were completely dry before stacking them; the food was covered after preparation; there were no flies in the kitchen and that Dietary Staff wore their hair net containing the hair on the back of their head. These deficiencies affected all residents who received food from the kitchen and could contribute to foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to arrange for the provision of hospice care under a written agreement to coordinate care provided by the LTC facility and hospice staff for 2 of 5 residents (Residents #13 and #55) reviewed for hospice services. 1. The facility failed to obtain Resident #13's most recent hospice Plan of Care, Physician's certification of the terminal illness and interdisciplinary documentation of the hospice staff providing services to the resident. 2. The facility failed to obtain Resident #55's most recent hospice Plan of Care, Physician's certification of the terminal illness and interdisciplinary documentation of the hospice staff providing services to the resident. [...]