Prairie Estates

The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #39's colostomy (an opening in the abdominal wall that allows waste to pass into a removeable pouch).

This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs.

Findings included:Review of Resident #24's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE].

Her diagnoses included paraplegia (impairment or loss of motor sensory function in the lower half of the body), multiple sclerosis (chronic autoimmune disease where the immune system attacks the central nervous system causing nerve damage), and encounter for attention to colostomy. Resident #24 had a BIMS of 15 which indicated her cognition was intact and the MDS further reflected the resident had a colostomy.

Review of Resident #24's care plan initiated on 10/30/24 did not reflect the resident had a colostomy.

Review of Resident #24's Order Summary Report for March 2026 reflected the following: Colostomy - Check Placement and Empty Contents every shift to ensure it is secured.

Empty Contents qshift and more often as necessary.Observation and interview on 03/26/26 at 12:03 PM, Resident #24 was observed sitting in her wheelchair alert and pleasant.

Observation of the colostomy site revealed it was clean, no redness and free of infection.

During an interview RN G stated they had never had any issues or concerns regarding the resident's colostomy site.

Interview on 03/31/26 at 3:40 PM, the MDS Nurse stated care plans were initiated by the ADONs or the nursing staff and she was not aware that Resident #24's colostomy status was not in her care plan.

The MDS Nurse said her colostomy status was on the previous computer system, and they switched to a new system in November 2025, and it appeared that her colostomy status has not transferred over.

The MDS Nurse stated it was the responsibility of the nursing management, herself included, to ensure care plans were not missed.

Interview on 03/26/26 at 4:18 PM, the ADON stated the MDS Nurse and nursing staff were responsible for implementing care plans.

The ADON stated she did not know why Resident #24's colostomy status was not in the current system and thought that when the facility changed computer systems in November 2025, the colostomy status might have been dropped.

The ADON said the MDS Nurses and other nursing staff were responsible for overseeing resident care plans to ensure they were accurate.

The ADON stated it was important to make sure care plans were accurate, so the staff knew how to take care of the residents and were updated on any changes.

Interview on 03/26/26 at 4:37 PM, the DON stated care plans were implemented by the nursing staff which included the MDS Nurse and the MDS Nurse was responsible for overseeing they were accurate.

The DON said he was not aware Resident #24's colostomy status was not on the current plan, and it appeared it might have dropped off when they switched to the new computer system in November 2025.

The DON said it was important to ensure resident care plans were accurate, so the staff knew how to take care of the residents.

Review of the facility's policy titled Comprehensive Care Plans dated 10/01/25 reflected the following: PolicyIt is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

676145 03/26/2026

Prairie Estates 1350 Main St Frisco, TX 75034

The facility failed to ensure Resident #137's intravenous medication bag and tubing were labeled with the date, time, and initials.These failures could place residents at risk for medication error, delay in medication administration, infections and cross-contamination.

Findings include:Findings include:

Record review of Resident #137's annual MDS Assessment, dated [DATE], reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #137's diagnoses included chronic respiratory failure with hypoxia (lungs cannot adequately transfer oxygen into the blood), hyperlipidemia (high cholesterol), Non-Alzheimer's Dementia (brain disorders causing cognitive decline), and anxiety disorder. Resident #137's BIMS score was 13, which indicated her cognition was intact.

Record review of Resident #137's care plan, dated [DATE], reflected: Focus: The resident is on antibiotic therapy (Ceftriaxone 1gm qd x 7 days) r/t infection UTI/Elevated WBC End date -[DATE].

Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date.

Interventions: Administer ANTIBIOTIC medications as ordered by physician.

Monitor/document side effects and effectiveness Q-SHIFT.

Record review of Resident #137's [DATE] physician orders reflected the following: Ceftriaxone Sodium Solution Reconstituted 1GM.

Use 1 gram intravenously one time a day related to Urinary Track Infection for 7 Days.

Order date [DATE].

Observation and interview on [DATE] at 2:38 PM, revealed Resident #137 in her room, sitting in her wheelchair watching television.

She was observed to have a PICC line on her left arm; it had a dressing with a date of [DATE]. No signs of redness or drainage were observed. Resident #137 stated she received her antibiotics at nighttime.

The intravenous medication bag was observed hanging on the pole and the IV tubing was not labeled with the date, time, and initials.Interview on [DATE] at 3:20 PM, LVN A stated she was the 2PM-10PM nurse assigned to Resident #137.

She stated Resident #137 was on antibiotics, and she received the antibiotics during the second shift. LVN A stated she was the nurse who provided the antibiotics on [DATE]. LVN A entered Resident #137's room and observed the intravenous medication bag hanging on the pole and stated the medication bag was missing the time, date and initial.

She stated she got busy and forgot to label the medication with the date and time when she hung it up.

She stated it was important to date, time and initial the medication bag and tubing so that next staff knows whether the tubing was good to be used.

She stated the tubing should be disposed after 24 hours.

She stated the potential risk of not dating and labeling the medication bag and tubing would be infection.

Interview on [DATE] at 2:37 PM, ADON stated she expected staff to date and initial the medication bag and tubing when administering the medications.

She stated staff should make sure they followed the 6 rights, right resident, right medication, right dosage, right route, right time, and right documentation.

She stated the potential risk of not dating and labeling the medication bag and tubing would be not knowing when it was administered.

Interview on [DATE] at 4:38 PM, the DON stated the expectation when administering IV medication, staff should check to make sure it was the correct medication, right patient, right time and ensure the medication was not expired. He stated staff should label the medication bag and tubing with the time and date.

The DON stated it should be labeled with the time and date so that the staff were aware of how long the medication had been infusing and know the duration of when the medication was hanged. He stated the potential risk would be staff not knowing when it was administered.

The DON stated he had done training with staff on labeling and putting initials on bags and tubing and had done skill checks with the nurse.

Record review of the facility's Intravenous Therapy policy, revised [DATE], reflected the following: The facility will adhere to accepted standards of practice regarding infusion practices.5.

All IV tubing is to be labeled with date, time and initials.

676145 03/26/2026

Prairie Estates 1350 Main St Frisco, TX 75034

The facility failed to ensure expired medications were removed from the Hall 100 medication aide cart and Hall 900 nurses' medication cart.

This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction.Observation on 03/25/2026 at 1:19 PM, Hall 100 medication aide cart revealed one bottle of Calcium 500mg/Vitamin D 400unit (used as dietary supplement designed to support bone health and improve calcium absorption with an expiry date of December 2025.Interview on 03/25/2026 1:30 PM, LVN E stated Medication Aide F was responsible for checking the cart for expired medications.

She stated failing to remove the expired medication could result in the medications being administered which could cause reactions, or the residents would not get the required therapy.Interview on 03/25/2026 1:40 PM, MA F revealed she was responsible for checking the cart for expired medications.

She stated she had not checked her cart on 03/25/26, she only checked every couple of days, and she was not specific on which days.

She stated failing to remove the expired medication could result in the medications being administered which could make residents sick.

She stated she could not recall training, but she had been instructed verbally to be checking the carts for expired medications.

Observation on 03/25/2026 at 1:57 PM, of the Hall 900 nurses' medication cart with RN G revealed, one bubble pack of Clonidine 0.1milligrams (used to treat high blood pressure) with an expiry date of 02/24/26 and one bottle of Tums (used to provide rapid relief for heartburn, acid indigestion, sour stomach, and upset stomach) with no expiry date.

Interview on 03/25/2026 1:57 PM, RN G stated she was responsible for checking the cart for expired medications.

She stated she had checked her cart for expired medications that morning , and she had missed the expired medication. RN G stated she checked her cart daily for expired medication and expiry dates.

RN G said failing to remove the expired medication and having medications with no expiry dates could result in the medications being administered which could cause the residents not to get the required therapy.

She stated the risk of having expired medication if administered it will not be effective.

She stated she had done training on cart audit, but she could not recall when.Interview on 03/26/2026 at 2:46 PM, the ADON revealed her expectation was for nurses to check their cart for expired medications every week.

She stated the ADON's were responsible for checking behind the nurses weekly.

She stated she last audited the carts on 03/23/25 and she also missed the expired medications.

She stated the risk of having expired medications on the cart was being administered, and they would not be effective.Interview on 03/26/2026 at 4:37 PM, the DON stated his expectation was all nurses were responsible for checking the carts weekly, to ensure expired medications were removed from the carts. He stated it was the responsibility of ADON to go behind the nurses weekly and ensure expired medications were being removed from the carts. He stated if expired medications get administered could place residents at risk of having side effects.Review of facility training records on 03/26/25 revealed facility training on carts audit and RN G was in attendance.

Record review of facility's Medication Administration policy dated 02/01/25 reflected: . 13.

Identify expiration date. If expired, notify nurse manager.

676145 03/26/2026

Prairie Estates 1350 Main St Frisco, TX 75034

licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the