Prairie Manor NRSG & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Prairie Manor NRSG & Rehab CTR, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 12, 2024

  Based on observation, interview, and record review, the facility failed to adequately supervise residents assessed as being at risk for falls and in the dementia unit, failed to make sure that fall interventions were implemented for 2 residents (R2 and R3) and failed to have any base line fall intervention/ adequate supervision for a newly admitted resident with history of falls (R1). These failures affected three (R1, R2 and R3) of five residents reviewed for falls/injury. These failures resulted in R1 having a fall in the dining that resulted in a right femur fracture, requiring surgery; R2 had a fall in her room and sustained a femur fracture requiring a surgical procedure; and R3 had a fall in her room and sustained a right distal clavicle fracture, which required treatment at a local… […]

• Actual harm, isolatedF600Aug 22, 2023

  Based on interviews and records reviewed the facility failed to prevent an incident of resident-to-resident physical assault. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R2 attacking R1 unprovoked with a belt to R1's leg. R1 being a severely cognitive resident it is reasonable to conclude this resulted in R1 suffering psychological feelings of fear after being attacked by R2. The Findings include: R1 has diagnosis including but not limited to Dementia, Major Depressive Disorder, Alzheimer's Disease, Generalized Anxiety Disorder, and Weakness. R1's cognitive assessment dated [DATE] is a 6, severely impaired. R2 has diagnosis including but not limited to Unspecified Dementia and Alzheimer's Disease. […]

• Actual harm, isolatedF689Nov 17, 2022

  Based on interview and record review, the facility failed to have effective fall interventions in place and failed to provide adequate supervision to ensure the safety of a resident assessed to be at risk for falls. This failure applied to one (R5) of one resident reviewed for accidents and supervision. This failure resulted in R5 having a fall with injury that resulted in a subdural hematoma and subsequently died . Findings include: R5 is a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis of but not limited to abnormalities of gait and mobility, restlessness and agitation, unsteadiness on feet, and Alzheimer's disease. On [DATE] R5 had a fall in the facility during which R5 hit his head and sustained a laceration to the right brow. […]

• Actual harm, isolatedF550Aug 25, 2022

  Based on observations, interviews, and record reviews, the facility failed to honor the residents' right to choose to be a resident of the facility by not honoring the residents' request to return home after completion of rehabilitation therapy. This failure applied to one of one (R93) resident reviewed for resident rights and has resulted in R93 suffering extreme stress and feeling symptoms of depression due to not being able to discharge from the facility. Findings include: R93 is an [AGE] year-old female admitted into the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/22/2022 surveyor observed R93 sitting up in her chair making phone calls. R93 was able to communicate to the surveyor and make needs and concerns known. […]

• Actual harm, isolatedF600Aug 25, 2022

  Based on observations, interviews, and record reviews, the facility failed to keep a resident free from mental abuse by not providing the resident with an explanation of why the facility is requesting a court appointed guardian for the resident. This failure applied to one of one (R93) resident reviewed for mental abuse and has resulted in R93 suffering extreme stress and feeling symptoms of depression due to not being able to discharge from the facility. Findings include: R93 is an [AGE] year old female admitted into the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/22/2022 surveyor observed R93 sitting up in her chair making phone calls. R93 was able to communicate to the surveyor and make needs and concerns known. […]