Prairie Manor Care Center

F-F310 (sun-setted regulation for ADL care). The policy outlined ADL(s) included hygiene care (i.e., bathing, grooming) and directed, Staff will complete documentation in POC every shift describing the amount of care needed to complete each ADL.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 13 245482 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245482 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Prairie Manor Care Center 220 Third Street Northwest Blooming Prairie, MN 55917

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47495

Residents Affected - Some 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 (Resident R18) observed and reviewed for safe transfers. This had the potential to affect five residents (Resident R4, Resident R8, Resident R9, Resident R18, Resident R24) residing in the facility who used the same practice for mechanical lift transfers.

Findings include:

Resident R18's quarterly Minimum Data Set (MDS), dated [DATE REDACTED], indicated Resident R18 had severe cognitive impairment, was dependent on staff for all activities of daily living (ADLs) and required a mechanical lift for transfers.

Resident R18's Weights, dated 7/2/24, in the electronic medical record (EMR) indicated Resident R18 had lost 32 pounds in the past 6 months, approximately 15% of her body weight with a current weight of 187 pounds.

Resident R18's care plan, printed 7/2/24, indicated Resident R18 required physical staff assist of two with VOLARO hoyer [mechanical] lift and size large (black trim cross leg sling) or the ARJO lift with (green trim) size large sling.

Resident R18's progress notes, dated 4/1/24 - 7/1/24, indicated Resident R18 had two falls from a mechanical lift on 4/14/24 and 6/1/24.

Resident R18's progress note, dated 4/14/24, indicated Resident R18 was transferring from her bed to wheelchair via a mechanical lift and two staff members when Resident R18 got ahold of the leg straps and started viciously shaking them. Resident R18 was up in the air when one of the leg straps came out of the hook holding it in place causing Resident R18 to fall from the mechanical lift and was lowered to the ground.

Resident R18's progress note, dated 6/1/24, indicated Resident R18 slid out of the hoyer [mechanical lift] sling and was lowered to the floor.

During an interview on 7/1/24 at 9:45 a.m., nursing assistant (NA)-D stated Resident R18 required assistance with two staff for transfers via a mechanical lift. NA-D stated Resident R18 often had aggressive behaviors during transfers. NA-D stated she was present with Resident R18 on 4/14/24, when Resident R18 grabbed the sling straps and started shaking them. NA-D stated Resident R18 was up in the mechanical lift and fell into the chair when the sling strap came lose. NA-D further stated the facility used multiple types of mechanical lifts and slings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 13 245482 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245482 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Prairie Manor Care Center 220 Third Street Northwest Blooming Prairie, MN 55917

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview on 7/1/24 at 9:50 a.m., the director of nursing (DON) stated the restorative nurses and

the assistant director of nursing (ADON) were responsible to assess what mechanical lift and sling were Level of Harm - Minimal harm or appropriate for a resident to use. The DON stated a resident would be reassessed for proper sling size if a potential for actual harm concern was noted or a change in condition but not necessarily from weight loss alone. The DON stated Resident R18 was using the proper care planned mechanical lift and sling when she fell on [DATE REDACTED], however the Residents Affected - Some mechanical lift was found to have a broken clip that may have contributed to the sling coming loose, and

after the second fall on 6/1/24 the sling was changed to a less slippery sling. The DON further stated the maintenance department provided routine maintenance of the mechanical lifts and nursing staff was educated on checking the clips on the mechanical lifts prior to use.

During an interview on 7/1/24 at approximately 1:00 p.m., the ADON stated after Resident R18's fall on 6/1/24, a different sling and mechanical lift was put in place to see if it would prevent Resident R18 from wiggling out of the sling. The ADON further stated they had not had the mechanical lift or sling companies out to the facility to do education with the staff on how to properly use the mechanical lifts and slings to prevent further falls from

a mechanical lift. The DON stated approximately 3 weeks ago she realized the facility was using three different types of slings and mechanical lifts, so each resident using a mechanical lift was assessed by the ADON for proper sling sizing.

During interview on 7/1/24 at 3:10 p.m., (via email) the DON confirmed Resident R18 was using a Volaro brand mechanical lift with Tollos brand sling when she fell from the mechanical lift on 4/14/24 and 6/1/24. The DON further confirmed while they had changed the mechanical lift and sling for Resident R18, other residents in the facility were still using a combination of the Volaro brand mechanical lifts and Tollos brand slings.

During an interview on 7/1/24 at 4:17 p.m., (via email) a Tollos (sling) Representative (TR) and the Tollos Clinical Educator (TCE) stated Tollos had not tested their slings to be used with the Volaro mechanical lifts and stated the most important aspect of using a Tollos sling with any other equipment would be if the facility received proper training for safe use. The TCE further stated Tollos does not make a recommendation in this regard because the possible combinations and uses would be numerous and could be unsafe in some situations. We would need to evaluate each individual use.

During an interview on 7/2/24 at 8:55 a.m., a Volaro mechanical lift representative (VR) stated Volaro does not recommend, as a manufacturer, the use of other branded slings with their lifts. The VR stated he had seen other slings on the Volaro lifts that may have appeared to have a strong hold but created unsafe gaps

in the sling where it should wrap the resident for safety to prevent a resident from slipping out. The VR further stated their slings were specifically designed to fit their mechanical lifts.

During an interview on 7/2/24 at 10:27 a.m., the DON stated they had processes in place to review quarterly what slings and mechanical lifts a resident was using to ensure appropriateness, but have not had any facility wide education on what staff should look for to determine if a mechanical lift or sling was not appropriate for a resident. The ADON stated she determined the Volaro brand mechanical lifts and the Tollos sling were appropriate to use together by visual inspection but did not reach out to the mechanical lift and sling companies for education or to assess if they were appropriate and safe to use together.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 13 245482 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245482 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Prairie Manor Care Center 220 Third Street Northwest Blooming Prairie, MN 55917

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 An undated policy titled Lifts & Transfers indicated the facility used a variety of mechanical lifts and slings for both sit to stand and full lift purposes and each resident would be assessed for an appropriate lift and sling Level of Harm - Minimal harm or based on the resident's height, weight, and body circumference. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 245482 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245482 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Prairie Manor Care Center 220 Third Street Northwest Blooming Prairie, MN 55917

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress Level of Harm - Minimal harm or disorder. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47495 Residents Affected - Few Based on observation, interview and document review the facility failed to comprehensively assess and reassess a resident's history of abuse and trauma, behavioral symptoms, triggers, and interventions to minimize physical and verbal aggression during cares for 1 of 1 resident (Resident R18) reviewed for behavioral management.

Findings include:

Resident R18's quarterly Minimum Data Set (MDS), dated [DATE REDACTED], indicated Resident R18 was admitted to the facility on [DATE REDACTED] and had severe cognitive impairment. The MDS further indicated Resident R18 was dependent on staff for all activities of daily (ADLs) and had verbal behavioral symptoms daily and physical behavioral symptoms 4-6 days of the 7 day look back period.

Resident R18's diagnoses list, printed 7/2/24, indicated Resident R18 had multiple medical diagnoses including unspecified dementia with behavioral disturbances and other specified mental disorders due to known physiological condition.

Resident R18's medication administration record (MAR), dated 5/24/24, indicated Resident R18 received several medications including Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia [a serious mental illness that affects how a person thinks, feels, and behaves] and bipolar disorder [severe mood swings]) 50 milligrams (MG) by mouth every morning and bedtime related to unspecified dementia with behavioral disturbance, dated 6/4/24 and escitalopram oxalate (used to treat depression and generalized anxiety disorder) 10 mg by mouth one time a day related to dementia with behavioral disturbance, dated 3/26/24. The orders also contained an order to monitor mood and behaviors d/t [due to] increase Seroquel 6/5 - every shift for 4 weeks.

Resident R18's care plan, printed 7/2/24, with revisions since admission, indicated problematic manner in which resident acts characterized by ineffective coping in unfamiliar environment. Agitation as e/b calling out and yelling at staff with cares related to: Dementia, cognitive decline, history of physical and emotional abuse. Can become very anxious at times and call out/verbalize with phrases such as: You're hurting me You're going to drop me I'm slipping I'm not safe. Has swatted and pinched staff and makes threats to hurt staff. History of yelling, swearing, and showing unwanted hand gestures when being provoked by other residents. History of yelling, swearing, hitting and attempts to bite staff during cares. The care plan contained the following interventions, that had not been updated since Resident R18's admission despite them being ineffective in decreasing Resident R18's care planned behaviors; Be sure you have the resident's attention before speaking or touching. Staff to maintain calm approach, provide support listening, reassurance and verbal cues with transfers and cares, Keep schedules and routine predictable and inform resident ahead of time before attempting cares, Monitor for verbal/nonverbal indicators of pain and report to nurse for further assessment if noted, Refer to transferring/toileting care plans. Staff to provide verbal cues and use 2a [assistance] with mechanical lift to ensure safety, Remove resident from public area when behavior is disruptive/unacceptable. Talk to resident in low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity offer food/fluid, toilet, nurse to assess for pain, ask resident about her farm or horses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 245482 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245482 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Prairie Manor Care Center 220 Third Street Northwest Blooming Prairie, MN 55917

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 Resident R18's medication administration record (MAR) and treatment administration record (TAR), dated 6/24, lacked any documentation of non-pharmacological interventions or as needed medication to address Resident R18's frequent Level of Harm - Minimal harm or and continued verbal and physical behaviors. potential for actual harm Resident R18's progress notes from 5/1/24 to 7/1/24, also lacked any non-pharmacological interventions but indicated Residents Affected - Few Resident R18 had behaviors on the following days and two falls from a mechanical lift;

On 5/1/24 it was documented Resident R18 was still very combative towards staff during cares.

On 5/2/24 it was documented Resident R18 was still very combative and using abusive language during cares.

On 5/3/24 it was documented Resident R18 was still very combative and using abusive language during cares.

On 5/6/24 it was documented Resident R18 continues to scream out at staff during cares. Swings out and hits at them, kicks, refuses cares, yells 'you're hurting me, ow that hurt!' Swears at staff and calls them names. Yells 'shut up' frequently when staff are providing cares. Behaviors do subside once cares are completed, after a bit. Is content when sitting in dining room or when lying in bed. Refuses care or yells during cares each time.

Resident R18's skilled nursing notes from 5/9/24 - 5/16/24 indicated Resident R18 has continued to yell and strike out at staff

during cares daily.

On 5/14/24 it was documented under RN Behavior Note nursing continues to note (Resident R18) has behaviors of screaming, yelling, use of abusive language and Hx (history) of being combative with ADLs and transfers. Primarily has almost daily behaviors of yelling and using abusive language with cares due to anxiety and fear. Explanation of task, calm approach, different staff, speaking in a calm voice is usually effective in allowing task to be fulfilled and behaviors do not continue once task is complete.

On 5/18/24 it was documented Resident R18 continues to yell and hit out with cares.

On 5/23/24 it was documented in a Care Conference note Resident R18 continues to have behaviors daily of yelling out, swearing and accusatory behaviors. At times does attempt to hit out at staff. Staff continues to try interventions, effectiveness varies. Resident is followed by Rural Psych Associates.

On 5/24/24 it was documented Resident R18 was yelling out and grabbing with am (morning) cares.

On 5/28/24 it was documented yelling/screaming, grabbing, pinching/scratching/spitting, abusive language, threatening behaviors was documented by the nursing assistants.

On 6/1/24 it was documented Resident R18 fell out of the hoyer lift during transfer. (An additional fall from the hoyer lift was documented on 4/14/24.)

On 6/4/24 it was documented Resident R18 was seen by Rural Psych and Seroquel was increased to 50 mg twice a day.

On 6/12/24 it was documented Resident R18 was yelling at staff while cares are being completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 245482 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245482 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Prairie Manor Care Center 220 Third Street Northwest Blooming Prairie, MN 55917

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 On 6/14/24 it was documented Resident R18 continued to yell and is combative with cares.

Level of Harm - Minimal harm or On 6/16/24 it was documented Resident R18 was yelling and combative with am (morning) cares. potential for actual harm

On 6/29/24 it was documented Resident R18 was yelling, pinching, and hitting the nursing assistants during cares. Residents Affected - Few

On 6/30/24 it was documented Resident R18 was yelling during cares.

On 7/1/24 it was documented Resident R18 was yelling during care.

Resident R18'2 EMR had evidence of medication changes to attempt to help with behaviors but lacked a comprehensive reassessment of specific triggers and interventions that have been attempted and worked or attempted and not worked to control Resident R18's anxiety surrounding personal cares due to a history of abuse, despite current interventions being ineffective.

Resident R18's Psychosocial History and Assessment, dated 9/1/22, indicated Resident R18 had a history of abuse by her son and a family history of alcohol. The form indicated Resident R18 did not have a history of mental health problems and lacked any initial observations of mood, personality, behavior, etc.

Resident R18's EMR indicated Resident R18 was seen by Rural Psychiatry Associates three times on 5/2/24, 5/9/24 and 6/4/24. The notes indicated Resident R18 continued to have aggressive behaviors but lacked any recommendations for staff on interactions with Resident R18 or non-pharmacological interventions despite continued behaviors.

Resident R18's Rural Psych note, dated 5/2/24, indicated the chief complaint was aggressive behaviors and agitation

during care. The note indicated Resident R18 presented with behavioral issues during care activities, exhibiting aggressive behaviors, yelling, and screaming when touched or moved. The note indicated Resident R18 had a history of trauma and abuse from her father and husband.

Resident R18's Rural Psych note, dated 5/9/24, indicated Resident R18 had no changes in behavior.

Resident R18's Rural Psych note, dated 6/4/24, indicated Resident R18's calling out seems to have improved minimally but she was more physically resistive.

During observation on 7/1/24 at 9:03 a.m., Resident R18 was sitting out at the breakfast table in the main dining area, resting calmly with her eyes closed.

During an interview on 7/1/24 at 9:45 a.m., nursing assistant (NA)-D stated Resident R18 had behaviors when being transferred or while staff were doing personal cares with her. NA-D stated she had been working with Resident R18 since November 2023 and Resident R18's aggressive behaviors seemed to be getting worse, stating Resident R18 kicked, hit and punched at staff during cares and used foul language.

During an interview on 7/2/24 at 10:43 a.m., NA-D stated she tried to treat all residents the same but she would be more understanding if she knew a resident had a history of abuse. NA-D she had heard that Resident R18 may have had something in her past but nothing that she was certain of.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 245482 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245482 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Prairie Manor Care Center 220 Third Street Northwest Blooming Prairie, MN 55917

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 During observation and interview on 7/1/24 at 10:10 a.m., NA-A, NA-B and NA-D were transferring Resident R18 from her wheelchair to her hospital bed via hoyer lift. Resident R18 was very agitated, yelling and screaming, I want to go Level of Harm - Minimal harm or home! Don't touch me! I don't like that guy! They broke my butt and it hurt! Resident R18 was observed trying to reach potential for actual harm out and grab staff. NA-A attempted to talk to Resident R18 in a calm, reassuring voice which was ineffective in calming Resident R18 down. No other non-pharmacological interventions were observed during cares. Resident R18 was provided Residents Affected - Few incontinent care and transferred back to her wheelchair via hoyer lift. NA-A stated they documented Resident R18's behaviors in Tasks but it was limited to check boxes therefore limiting what they could document.

During an interview on 7/1/24 at 1:05 p.m., licensed practical nurse (LPN)-B stated Resident R18's behaviors mostly centered around cares. LPN-B stated documentation for mood and behavior was on Resident R18's MAR but non-pharmacological interventions were not, stating usually for residents with behavior who were taking antipsychotic medications, non-pharmacological interventions would be on the MAR to allow staff to note which interventions were used and effective. LPN-B stated nothing really works for Resident R18's behaviors, stating when she was first admitted to the facility, Resident R18 talked more and LPN-B was aware of a history of some sort of abuse but she was unaware of specifics because nothing was care planned regarding the specifics of Resident R18's history of abuse.

During an interview on 7/1/24 at 1:12 p.m., social services director (SSD) stated she assisted with assessing care planning a residents' potential history of abuse or trauma. The SSD stated when Resident R18 was first admitted

she was more cognitively intact and reported physical abuse by her father and husband and the SSD believed there was some financial abuse by her son. The SSD stated they did not have a formal reassessment process to track what interventions effective or did not, stating interventions will work for one resident and not another. The SSD confirmed interventions had not been updated since Resident R18's admission on how to help control Resident R18's aggressive behaviors, stating she used to like to talk about the farm she grew up

on and horses but she had declined cognitively to the point so no longer remembered and was living in the past where her abuse was current to her. The SSD further stated the intervention to provide Resident R18 with her [NAME] doll was no longer working. The SSD stated they have been trying to find triggers but her aggression seems to be just during cares.

During an interview on 7/2/24 at 10:16 a.m., the director of nursing (DON) stated social services was responsible for the initial psychosocial assessment and that quarterly the nurses would complete a Behavior Note in progress notes that assessed dose reduction of medications, oral intake, and cognitive status. (The assessment lacked a look at specific interventions and triggers for behaviors.) The DON stated she was aware of Resident R18's aggressive behaviors as her office was across the hall from Resident R18's room and she could hear her yelling with cares daily. The DON confirmed Resident R18 lacked a comprehensive assessment and reassessment of her history of abuse and trauma and a reassessment of interventions despite care planned interventions being ineffective.

A facility policy titled Behavioral Health Services Policy, dated 8/31/17, indicated behavioral health encompasses a resident's whole emotional and mental well-being: and it was the policy of the facility to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and to ensure that a resident whose assessment did not reveal a mental/psychological disorder did not display decreased social interaction or increased withdrawn, angry or depressive behaviors unless the resident's clinical conditions demonstrated that this was unavoidable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 245482 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245482 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Prairie Manor Care Center 220 Third Street Northwest Blooming Prairie, MN 55917

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 44656

Residents Affected - Some Based on observation and interview the facility failed to ensure a container of oranges was stored off the floor to protect from contamination. This had the potential to affect all residents who consumed food served from the main kitchen.

Findings include:

During the initial kitchen tour of facility with cook (C-A) on 6/30/24 at 10:16 .m., a cardboard box of oranges was observed on the floor of the walk-in refrigerator next to wire racking containing refrigerated food. C-A stated, no it should not be on the floor.

During interview with dietary director (DD) on 6/30/24 at 1:55 p.m., DD stated, the oranges should not have been on the floor of the fridge. We got a shipment on Friday [6/28/24] and . they should have been put up on

a shelf in the fridge.

During interview with C-C on 7/2/24 at 8:48 a.m., C-C stated, oranges should not be on the floor [sic] cause that is contamination [sic] and should be 6 inches off the floor. We go through a lot of oranges here too. That is not ok.

Undated facility policy titled Perishable Food Storage Areas state, 1. All items must be stored at least 6 inches off the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 245482