Prairie Oasis

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 20, 2026

  Based on observation, interview, and record review, the facility failed to provide a hazard free environment for two (R1, R5) of 4 (R1, R2, R4 and R5) residents reviewed for hazards/supervision. This failure resulted in R1 getting out of bed and falling on an uncovered radiator heater resulting in R1 suffering second degree burns to the right shoulder and right hip and admitted to the hospital's burn intensive care unit for evaluation and treatment of severe burns. This failure also resulted in R5 suffering a laceration to the left eye that required sutures, subdural hematomas that required R5 to be admitted to the hospital's intensive care unit and ultimately resulted in admission to hospice due to the subdural hematoma. […]

• Actual harm, isolatedF686Feb 8, 2026

  Based on interview and record review, the facility failed to ensure timely assessment and implementation of preventative measures to prevent the development of a pressure ulcer for one (R1) of three residents reviewed for pressure ulcers. This failure resulted in R1 developing a facility-acquired Stage 3 pressure ulcer to the coccyx.Findings include: R1 is a [AGE] year-old resident admitted to the facility on [DATE] to 11/13/25 with diagnoses including but not limited to: atrial fibrillation, seizure, hypertension, cerebrovascular accident, obesity, depression, cognitive and communication deficit, dementia, cerebral amyloid angiopathy, anxiety, history of encephalopathy, and coronary artery disease. […]

• Actual harm, isolatedF600Dec 18, 2025

  Based on observation, interview and record review, the facility failed to prevent staff to resident physical abuse and neglect. These failures resulted in R1 sustaining a fractured left humerus and R3 sustaining moisture associated skin damage/skin breakdown. These failures affected two (R1 and R3) of six residents reviewed for abuse/neglect. Findings include:1) R3's face sheet documents, R3 is an [AGE] year-old resident and has diagnoses including, but not limited to: cirrhosis of the liver, unspecified supracondylar fracture of the left humerus, dementia without behavioral disturbance, unspecified protein calorie malnutrition, other disorders of bone density and structure, functional quadriplegia and metabolic encephalopathy. […]

• Actual harm, isolatedF677Dec 18, 2025

  Based on observation, interview and record review, the facility failed to provide incontinence care and showers for one (R1) resident that was dependent on staff for ADL (activities of daily living) care. This failure affected one (R1) of six residents reviewed for ADL care. This failure resulted in R1 experiencing pain and development of moisture associated skin damage (open areas). R1's face sheet documents in part that R1 is a [AGE] year-old resident with a prior medical history including: hemiplegia affecting left side, type 2 diabetes mellitus, depression, hypothyroidism, and hypertension. R1's MDS dated [DATE], documents R1 has a BIMS summary score of 13, indicating that R1 is cognitively intact. […]

• Actual harm, isolatedF689Sep 12, 2025

  Based on interview and record review, the facility failed to ensure that two-person assistance was utilized during resident care, as required by the resident's care plan, to maintain safety. This deficient practice affected one of three residents (Resident #13) reviewed for safety during care. As a result, Resident #13 fell from the bed during care, which led to the dislodgement of the resident's gastrostomy tube and required hospitalization for replacement. On 9/12/25 at 9:37 AM, R13 was observed able to nod head yes or no to questions asked. When questioned if able to raise arms off bed, R13 nodded head 'no'. On 9/9/25 at 4:00 PM, V2 DON (director of nursing) stated V2 wrote up V9 CNA (certified nurse aide) for improper care resulting in R13's fall out of bed. […]