Western Prairie Senior Living LLC

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent when 25 medication administration opportunities were observed with two medication errors identified for Resident (R) 10. This resulted in a medication error rate of eight percent.

Inspectors wroteThe facility reported a census of 33 residents, and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent potential for food borne bacteria.

Inspectors wroteThe facility reported a census of 33 residents. Based on observation, record review and interviews, the facility failed to promote a comfortable, sanitary, and homelike environment when the temperature in the activity room was below comfortable level, and chairs in the common area were worn with visible cushion-stuffing on the arms.

Inspectors wroteThe facility reported a census of 33 residents, the sample included 12 residents. Based on interview and record review, the facility failed to inform Resident (R) 17 and/or her representative regarding the risks related to psychotropic (alters mood or thoughts) medications.

Inspectors wroteThe facility reported a census of 33 residents; the sample included 12 with one resident reviewed for prevent decrease in range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) and mobility. Based on observation, interview, and record review, the facility failed to provide a hand carrot (most commonly refers to a hand contracture [abnormal permanent fixation of a joint or muscle] device, a tapered, carrot-shaped medical device used to position fingers away from the palm in cases of severe hand spasticity or contraction) to Resident (R) 8.

Inspectors wroteThe facility reported a census of 33 residents which included a sample of 12 residents and one resident reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards when staff failed to provide adequate supervision which allowed Resident (R) 1 to exit the facility without staff knowledge or supervision.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure medications were available for administration, as ordered by the physician, for Resident (R) 17.

Inspectors wroteThe facility reported a census of 33 residents, with 12 residents sampled, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon thepharmacist's monthly medication regimen review (MRR) for Resident (R) 17 and R8.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to prevent a significant medication error when the facility did not administer Resident (R)17's antidepressant (a class of medications used to treat mood disorders) medication for six consecutive and never notified the physician.

Inspectors wroteThe facility reported a census of 33 residents with 12 residents sampled. Based on observation, interview and record review the facility failed to maintain an effective infection control practices for three residents, Resident (R) 7, R4, nd R2 related to incorrect use of personal protective equipment (PPE - gowns, face shields and/or eyeglasses/goggles, and gloves), lack of appropriate hand hygiene and inadequate enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) during high contact cares. The facility further failed to initiate contact precautions while awaiting culture results for clostridium difficile (C-diff- contagious bacterial infection characterized by foul-smelling frequent loose bowel movements).

Inspectors wroteThe facility reported a census of 33 residents. Based on observation, record review and interviews the facility failed to promote a safe, sanitary environment on the ceilings throughout the residents rooms as well as the dining room and activity room.

Inspectors wroteThe facility reported a census of 39 residents. Based on interview and record review, the facility failed to staff the facility with a Registered Nurse (RN) for eight consecutive hours each day, as required.

Inspectors wroteThe facility reported a census of 39 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS {i.e., Payroll Base Journal (PBJ)}, related to licensed nursing staff coverage 24 hours a day and Registered Nurse (RN) coverage for eight consecutive hours each day.

Inspectors wroteThe facility reported a census of 39 residents with 12 residents sampled. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff, failed to clean a full body mechanical lift between resident uses, to change gloves and perform hand hygiene between phases of incontinence care and to perform hand hygiene between resident room contacts when delivering laundry to resident rooms. This deficient practice has the potential to lead to cross contamination between residents and negatively affect every resident in the facility.

Inspectors wroteThe facility census totaled 39 residents. Based on observation, interview, and record review the facility failed to provide a sanitary environment by the failure to have lids on the trash cans in the soiled utility rooms. This deficient practice had the potential to be an unsanitary environment which would affect all residents in the facility.

Inspectors wrote- The Electronic Health Records (EHR) documented R29 had the following diagnoses that included pressure ulcer ( localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral region (small triangular bone at the base of the spine) and urinary tract infection (UTI - an infection of the lower urinary tract including the bladder and urethra [the tube that carries urine from the bladder to the outside of the body]). The 09/07/23 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment documented R29 did not have an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). [...]

Inspectors wroteThe facility census totaled 39 residents with 12 included in the sample. Based on observation, interview and record review the facility failed to develop a comprehensive care plan for Resident (R)7 by the failure to include the resident's pressure ulcer.

Inspectors wroteThe facility census totaled 34 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the consultant pharmacist identified missing parameters for Metoprolol (blood pressure medication), identify missing Abnormal Involuntary Movement Scale (AIMS), and notify the facility of an inappropriate diagnosis for the use of Risperdal (an antipsychotic) for Resident (R)11. The facility also failed to respond to the recommendation to attempt a Gradual Dose Reduction (GDR) of Cymbalta (an antidepressant) for R1.

Inspectors wroteThe facility census totaled 34 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure parameters were documented for Metoprolol (blood pressure medication) for Resident (R)11, and the facility failed to notify the physician of blood glucose results outside of parameters for R1 and R4.

Inspectors wroteThe facility reported a census of 34 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure one of five residents did not receive unnecessary medications when the facility did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment before initiating Risperdal (antipsychotic medication) and the facility did not ensure an appropriate indication for prescribing Risperdal for Resident (R)11.

Inspectors wroteThe facility reported a census 34 residents. Based on observation, interview, and record review the facility failed to inform the residents who attended resident council of the location of the state survey notebook and failed to inform the residents of the right to read the survey results.