Prairie Manor Care Center

In the surveyor’s words

From the most serious findings on record at Prairie Manor Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Feb 14, 2024

  Based on interview and document review, the facility failed to assess, implement care and interventions, and provide timely notification for change in condition to a provider for an unresponsive resident (R1) that delayed care resulting in risk of seizure, coma, or death to 1 of 3 residents (R1). Additionally, the facility failed to assess, implement care and interventions, and provide timely notification for a change condition to a provider for a resident (R1) who, during a transfer between two surfaces, felt a pop sensation near her right knee, and afterwards reported severe pain, and could no longer bear weight. […]

• Immediate jeopardy, isolatedF689Aug 19, 2022

  Based on observation, interview, and document review the facility failed to ensure manufacturer recommendations were followed for a mechanical lift transfers and failed to a comprehensive assessment residents safety when using a mechanical lift. This resulted in immediate jeopardy (IJ) for R1 who used an incorrect harness, had limited ability to bear weight and became suspended in the lift resulting in a T9 spinal fracture. In addition the facility failed to comprehensivly assess safe transfers for appropriate brand of mechanical lift, harness/sling size and type to ensure safe transfers for 4 of 12 residents (R2, R3, R5, R6) that used a mechanical lift. The IJ began on 8/12/22, at 3:15 p.m. […]

• No harm, potential for more than minimal, patternF689Jul 2, 2025

  Based on observation, interview, and document review, the facility failed to ensure assist bars attached to the bed were assessed and reassessed for specific hazards and risks and in accordance with manufacturer's guidelines for 4 of 4 residents (R19, R17, R24, R14) reviewed for assistive devices. Findings include:R19's quarterly Minimum Data Set (MDS) assessment, dated 4/28/25, identified severely impaired cognition, and physical behavior daily during the seven day lookback period. R19 was dependent for bed mobility and transfers and had a diagnosis of unspecified dementia with behavioral disturbances. R19's Cognitive Loss Care Area Assessment (CAA) dated 8/6/24, identified a diagnosis of dementia and extensive assist was required with ADLs (activities of daily living). […]

• No harm, potential for more than minimal, patternF657Jul 2, 2024

  Based on observation, interview, and document review the facility failed to ensure care plans, which the facility used to communicate Enhanced Barrier Precautions (EBP), were revised for 4 of 4 residents (R10, R16, R24, R31) who were reviewed for care plans and who had been placed on EBPs designed to reduce the spread of multidrug-resistant organisms (MDRO's). Findings include: The Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Quality, Safety and Oversight Group Ref: QSO-24-08-NH dated March 20, 2024, documented Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care… […]

• No harm, potential for more than minimal, patternF689Jul 2, 2024

  Based on observation, interview and document review the facility failed to comprehensively assess for and use the compatible mechanical lift with mechanical lift sling to ensure safe transfers for 1 of 1 residents (R18) observed and reviewed for safe transfers. This had the potential to affect five residents (R4, R8, R9, R18, R24) residing in the facility who used the same practice for mechanical lift transfers. Findings include: R18's quarterly Minimum Data Set (MDS), dated [DATE], indicated R18 had severe cognitive impairment, was dependent on staff for all activities of daily living (ADLs) and required a mechanical lift for transfers. […]