The Green Prairie Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at The Green Prairie Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 31, 2026

  Based on observation, interview and document review, the facility failed to ensure a safe transfer using a mechanical lift was completed for 1 of 1 resident (R1) reviewed. R1 was resistive to care and did not want to get up from the bed, however, two staff members proceeded to place a hoyer sling underneath her and began to transfer her from the bed to a shower chair despite R1 being resistive. R1 became more physically behavioral while in the device (i.e., wiggling around, moving) which caused her shoulder to nudge free from the sling mid-air and resulted in an avoidable fall from the lift. R1 sustained a scalp hematoma (i.e., goose egg) with bleeding, bruising on her left side, increased pain, and mental anguish (i.e., tearfulness) from the event which constituted actual harm. […]

• No harm, potential for more than minimal, patternF809Oct 31, 2024

  Based on interview and document review, the facility failed to offer and/or provide a suitable and nourishing snack after dinner and before bedtime when there were more than 14 hours between the evening and morning meals. This had the potential to affect all residents in the facility who would require a snack. Findings include: The facility provided a survey preparation binder which included an undated flyer titled Mealtimes: Breakfast - 8:00 a.m. Lunch - 12:00 p.m. Dinner - 5:00 p.m. During an observation on 10/29/24 at 2:08 p.m., a wicker basket was on the counter in the resident dining room. The basket contained applesauce, granola bars, pudding, animal crackers and rice krispie bars. […]

• No harm, potential for more than minimal, patternF880Mar 31, 2022

  Based on observation, interview, and document review, the facility failed to ensure hand hygiene was completed by 3 of 12 staff (NA-A, RN-A, and NA-B) observed prior to providing cares for 6 residents (R14, R4, R30, R37, R36 and R26). The facility was having a gastro-intestinal illness outbreak at the time. Findings: On 3/28/22, 1:45 p.m. two carts with personal protective equipment (PPE) were observed on the 200 hallway with signage posted on the doors to R22's and R10's room and R32's room, indicating persons entering the room should use, contact precautions (use PPE of gown, gloves and mask). Shortly after this, an additional cart with supplies was brought to a nearby room and a sign posted on R238's door also indicating staff were to use, contact precautions. On 3/28/22, 2:33 p.m. […]

• No harm, potential for more than minimal, isolatedF744Aug 31, 2026

  Based on observation, interview, and document review, the facility failed to comprehensively assess and, if needed, develop or implement interventions to reduce distress and behaviors on bath days for 1 of 3 residents (R1) reviewed. R1 displayed signs of dementia with obvious cognitive impairment and was identified by the staff to have increased behaviors on her bath/shower days but the medical record lacked evidence this had been evaluated by the interdisciplinary team (IDT) to determine if additional interventions were needed.Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had moderate cognitive impairment and no symptoms of delirium. […]

• No harm, potential for more than minimal, isolatedF565Dec 4, 2025

  Based on observation, interview, and document review, the facility failed to ensure residents call lights were answered in a timely manner for 2 of 2 residents (R6, R7) reviewed for grievances. Findings include: R7During an interview on 12/1/25 at 1:04 p.m., R7 stated she sometimes waits 45 minutes before staff respond to her call light. R7 reported I'm not supposed to be walking but sometimes I have to otherwise I have accidents. R7 also reported she has to search for staff when her urinary catheter bag is full. R7's comprehensive Minimum Data Set (MDS) assessment, dated 9/4/25 indicated R7 had mild cognitive impairment.R7's grievance form indicated on 10/2/25, the administrator answered R7's call light. R7 reported to the administrator her call light had been on for a long time. […]