Prairie Pines Assisted Living Community

Deficiency cited from Occurrence #2523A938002. The facility failed to provide the final report for Physical Abuse occurrence event #2523A938002.The findings:A. The facility submitted an initial Physical Abuse occurrence report on 4/25/25. The facility failed to provide the final report within the required timeframe. Department staff sent electronic late final report notices through the COHFI system on 5/13/25 and 5/21/25. On 9/12/25 the Department staff called the facility and left a message with the facility staff member. A response was not received.On 9/25/25, an external email was sent to the facility representative requesting submission of the final report. On 9/30/25 the Department staff sent a message with technical assistance. No response was received from the facility. As of 11/7/25, the facility had not submitted the Final Report.

A Relicensure Survey and complaint, prompted by #CO39547 and #CO39282, was completed on 7/9/25. Deficiencies were cited. Based on observation and interview, the residence failed to maintain outdated and discontinued medications in a locked storage area until properly disposed of. Specifically, controlled substance medication, affecting one out of three sample residents (#7).Findings include:The residence policy, Medication Administration dated 6/25/23, read in part that all medications shall be destroyed in a manner that renders the substance totally irretrievable. Furthermore, the disposal must be witnessed and a form must be signed and dated.Resident #7 had a physician order to receive a 50 mg fentanyl patch every other day.On 7/8/25 at approximately 9:45 a.m., Staff #2 removed a fentanyl patch from Resident #7' s body and discarded the patch in Resident #4' s trash receptacle.On 7/9/25 at approximately 11:45 a.m., Staff #1 stated that they discard Resident #4' s fentanyl patch either in her trash receptacle or in the trash receptacle in the unlocked med room.On 7/9/25 at 2:30 p.m., the administrator acknowledged that controlled subst.. Based on record review and interview, the administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records affecting four out of four current sample list (#4, #5, #6, #7).Findings include:The residence' s policy, Medication Administration policy dated 6/25/23, read in part, that the facility administrator is responsible for ensuring adequate professional oversight of the medication and treatment systems. Furthermore, the policy stated that the residence will conduct, on a monthly basis, a joint two person audit of medications designated for disposal. On 7/8/2025 at approximately 9:45 a.m., medication audits were requested. However, they were not provided.On 7/8/25 at 9:45 a.m., the administrator stated that she had not completed any medication audits from February to July 2025. She also said she was working to catch up on her administrative duties. Based on record review and interview, the resident failed to have a readily available roster of current residents, their room assignments, and emergency contact information, along with a facility diagram showing room locations, affecting 15 current residents.Findings include:On 7/8/25 at approximately 8:00 a.m., Staff #1 provided a resident roster that did not include a facility diagram showing room locations.On 7/8/25 at approximately 11:15 a.m., the administrator provided a diagram of the facility but was not currently showing the room locations. On 7/9/25 at 2:45 p.m., the administrator acknowledged that the roster did not include a facility diagram with the current information and that she was in the process of updating the diagram.

A licensure complaint, prompted by #CO38137 was completed on 11/20/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure that qualified medication administration persons (QMAP) did not administer as-needed medications (PRNs) to residents who were not capable of requesting the medication affecting one sample resident (#3). Findings include:Resident #3 was admitted to the residence on 11/1/23 with a diagnosis of senile degeneration of the brain. The record of Resident #3 revealed they were restless the night of 11/13/24 and not sleeping. The power of attorney (POA) delivered lorazepam, 0.5 mg to the residence so residence staff could administer the PRN medication to the resident. The medication administration record (MAR) revealed the medication was administered on 11/13/24 at 11:45 p.m. with the POA as a witness. The record revealed the residence did not have a medication order from a practitioner for the lorazepam administration.On 11/20/2024 at approximately 1:20 p.m., Staff #2 and #3 stated the MAR read Staff #1 administered the PRN medication to Resident #3 on 11/13/2.. Based on observation and interview, the residence failed to ensure all medications were stored in a locked storage area when unattended by a qualified medication administration person (QMAP) or other licensed staff, affecting 13 current residents. Findings include:On 11/20/24 from 7:45 a.m. to 12:00 p.m., an environmental tour revealed the staff office door was left open and unlocked and unattended. In the staff office, there were two bottle of vinegar where staff destroyed expired/discontinued medications. During that time, six residents were observed walking past the office on one or more occasions.On 11/20/24 at approximately 12:00 p.m., Staff #2 closed the door when asked if the staff office door was typically left open but did not lock the door. Staff #2 stated the door was left open most of the time. On 11/20/24 at approximately 2:00 p.m., the administrator stated she was not aware that the door was being left open on a daily basis. The administrator stated the door should be closed but they did not lock it. The adm.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 2.2.9.6 Each licensee shall submit to the Department a letter of intent of any change in the information required by Part 2.3.3 of this Chapter from what was contained in the last submitted license application. (A) Changes to the operation of the facility or agency shall not be implemented without prior approval from the Department. A licensee shall, at least thirty (30) calendar days in advance, submit a letter of intent to the Department regarding any of the following proposed changes. (2) Change in a management company or proposed use of a management agreement not previously disclosed.