Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Western Prairie Senior Living Llc during CMS and state inspections, most recent first.
Medication administration errors exceeded the allowed rate after two errors were found in 25 observed opportunities. An LPN administered a nebulized budesonide treatment without offering the resident a mouth rinse afterward, and a CMA gave Metamucil fiber in an amount observed as 10 ml even though the order was for 2 Tbsp. Staff acknowledged the expected administration practices and the facility policy required medications to be given according to the physician order and label.
Food Storage, Labeling, and Sanitation Deficiencies: Kitchen observations found an unsealed 50-lb bag of rice, multiple food items without open dates, unsealed sliced cheese, unlabeled salad, and other dated items missing labels. The freezer had a box of rolls on the floor and employee tamales, while the dishwasher was used without the aide knowing how to check temp or use a temp log, and the gauge read 80 degrees F. The kitchen also had stained and scratched cutting boards, a muffin tin with baked-on residue, damaged pans and lids, and an ice machine vent leaning over a dirty hole.
A resident was observed in the activity room wrapped in a blanket while the room felt chilly and measured about 64 degrees F, below the posted 70-75 degrees F range. Staff acknowledged the room was too cool and noted the area was on the cooler side of the building. In addition, two common-area chairs had worn fabric with white stuffing showing on the arms, and staff stated the chair surfaces did not appear cleanable.
Failure to Obtain Informed Consent for Psychotropic Medications: A resident with dementia, psychotic disorder, and major depressive disorder was receiving an antidepressant and antipsychotic, but the record lacked evidence of informed consent for either medication. Staff stated the consent process had not been completed, despite the resident being alert, oriented, and able to understand and communicate.
A resident with CVA, hemiparesis/hemiplegia, chronic pain, and impaired cognition did not consistently receive a hand carrot ordered in the care plan to keep the left hand open. EMR review showed the device was often charted as non-applicable, and observations found the resident several times with the left hand clenched shut and no device in place. Staff interviews indicated the restorative aide was the only person applying the hand carrot and that missed applications were documented when the resident was asleep.
Failure to supervise a resident with severe cognitive impairment and wandering behaviors allowed the resident to exit through the front door after following a visitor. The resident had Alzheimer’s disease, dementia, a BIMS score of 3, and an elopement bracelet, yet staff observed repeated pacing, wandering, and agitation when redirected. Security footage and staff statements showed the resident left the building when the door alarm sounded and a visitor exited, and the visitor could not read the English-only warning sign.
A resident with dementia, psychotic disorder, and major depressive disorder missed six doses of ordered fluvoxamine because the medication was not available or had not been received. The MAR and orders notes documented repeated missed doses, while staff interviews showed CMAs were expected to notify the nurse when a medication was unavailable and the nurse was responsible for reordering from the pharmacy. The facility policy stated refill medications should be ordered in advance to maintain an adequate supply.
Failure to Act on Pharmacist MRR Recommendations: The facility did not timely act on the consultant pharmacist’s MRR recommendations for two residents receiving psychotropic medications. One resident had dementia, psychotic disorder, and depression, and the EMR lacked the pharmacist report and physician response to recommendations for Neurontin and Cymbalta. Another resident had CVA-related deficits and depression; the physician response to the Cymbalta recommendation was not documented until months later. Staff interviews confirmed MRRs were routed to physicians, but nursing did not see them until after review.
A resident with dementia, psychotic disorder, and major depressive disorder missed six consecutive doses of fluvoxamine after the medication was documented as not available or not received. The MAR showed the missed doses, but there was no evidence the physician was notified, and the behavioral health provider later confirmed she had not been informed. Staff interviews confirmed the missed doses and that provider notification was expected for any medication not administered.
The facility failed to maintain infection control practices for three residents, including improper PPE use, missed hand hygiene, and inadequate EBP during high-contact care. During observed incontinence care, two CNAs entered a resident’s room without hand hygiene, used gloves and gowns incorrectly, reused wipes in a way that did not follow clean-to-dirty technique, changed gloves without consistent hand hygiene, and later removed PPE without cleaning their hands. The report also noted that a resident with a stool culture ordered for C-diff had not been placed on contact precautions while results were pending.
Unsafe and Unsanitary Environmental Conditions: Surveyors observed missing ceiling tiles in 31 of 33 resident rooms, with discolored ceiling tiles in hall areas near the dining room and activity room. Maintenance Staff U stated the old HVAC system caused the tiles to get wet and fall from the suspended ceiling, and that tiles were removed so water drips could be seen. The dishwasher was also observed at 80 degrees F during the survey after plumbing had been connected incorrectly to the cold piping, and the facility did not provide a policy.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent after 25 medication administration opportunities were observed and two medication errors were identified for R10, resulting in an eight percent error rate. R10 had physician orders for budesonide suspension 0.25 mg/2 ml vial to be inhaled orally via nebulizer twice daily for interstitial pulmonary disease, with instructions to rinse the mouth after use and to give the medication separately without mixing it with other nebulizer solutions. R10 also had an order for Metamucil fiber, 2 tablespoons by mouth once daily for bowel management, mixed with eight ounces of fluid. During observation, LN G administered the budesonide suspension by nebulizer and then removed the mask and rinsed the equipment for another breathing treatment, but did not offer R10 a mouth rinse after the medication. LN G later stated she should have offered a rinse of water after removing the first breathing treatment. In a separate observation, CMA R administered R10's Metamucil fiber by pouring medication from a stock bottle into the cap and then into a cup; when asked to verify the amount, 10 ml was observed in the measuring cup, and CMA R stated that was the amount she gave every day and that it was 2 tablespoons. LN G stated she expected the CMAs to provide the correct dose, and Administrative Nurse D stated she expected LNs and CMAs to administer all medications correctly as ordered. The facility policy stated medications are to be administered in accordance with written physician orders and the medication label should be read and compared with the MAR before pouring.
Food Storage, Labeling, and Sanitation Deficiencies
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions to prevent potential for food borne bacteria. During the initial kitchen tour, a 50-pound bag of rice was found unsealed on the bottom shelf in dry storage, and several food items did not have open dates, including food coloring, a gallon of corn syrup, a bottle of vanilla, a gallon of milk, and a gallon of thousand island dressing. In the refrigerator, a bag of sliced cheese was unsealed, a mixed salad had no date or label, and a container of salsa and a bag of cauliflower also had no dates. Additional observations showed a box of rolls on the freezer floor and a bag of tamales for an employee. A Dietary Aide used the dishwasher but reported he was not sure how to check the temperature and did not know about any temperature log; the temperature gauge showed 80 degrees Fahrenheit. The ice machine vent was leaning on the floor over a dirty hole. The kitchen also contained several stained and scratched cutting boards, a muffin tin with baked-on brown crusted areas, pans with dents and scratches, hard black substances on the cooking area surface, a large cooking pot with several dents, and cracked and broken plastic lid covers. Administrative Staff A stated that everything should be labeled with a date and sealed, and that kitchen equipment should be in good working order and clean.
Uncomfortable activity room temperature and worn common-area chairs
Penalty
Summary
The facility failed to maintain a comfortable, sanitary, and homelike environment when the activity room temperature was below the posted acceptable range and common-area chairs were visibly worn. During an observation, two green chairs by the 200-hall entrance had worn fabric on the arms with white stuffing showing. In the activity room, a nonverbal resident was observed sitting and watching television while wrapped in a blanket, and the room felt chilly; the ambient temperature was approximately 64 degrees Fahrenheit, despite a sign above the thermostat directing that it be kept between 70 and 75 degrees Fahrenheit. Administrative staff acknowledged the temperature issue during the observation and increased the thermostat setting. Later, staff stated the activity room was on the cooler side of the building and confirmed the temperature was inadequate. Staff also stated the green chairs in the 200-hall lobby had worn-down fabric and that the surface of the chair arms did not appear cleanable. The facility reported that a service company later confirmed heating valves had been closed and that the units were then functioning properly, and no policy was provided.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform a resident and/or her representative regarding the risks related to psychotropic medications. The resident had diagnoses of dementia, psychotic disorder, and major depressive disorder. Her record showed a BIMS score of 15, indicating intact cognition, and the psychotropic drug use CAA documented that she was alert, oriented, and able to make herself understood and understand others. The CAA also noted hallucinations, delusions, sadness more than half the days, and that she stated she would be better off dead related to the hallucinations she was having. The resident’s care plan directed staff to monitor for side effects from antidepressant and antipsychotic medications, and her EMR showed orders for fluvoxamine and risperidone. However, the clinical record lacked evidence of informed consent for fluvoxamine and for risperidone. During interviews, nursing staff stated that Administrative Nurse E would obtain consents for psychoactive medications, and Administrative Nurse E reported that no consent had been completed for the resident’s fluvoxamine or risperdal as of the interview date. The facility policy required that prior to initiating or increasing a psychotropic medication, the resident, family, and/or representative be informed of the benefits, risks, including black box warnings for antipsychotics, and alternatives, with written consent serving as evidence of consent.
Failure to Provide Ordered Hand Carrot and Restorative ROM Support
Penalty
Summary
The facility failed to provide a hand carrot for a resident with hemiparesis/hemiplegia, CVA history, chronic pain, and moderately impaired cognition. The resident’s EMR, MDS, and CAA documented dependence for ADLs and mobility, impairment to one side of the upper and lower extremities, and participation in restorative therapy to maintain strength and ROM. The care plan directed staff to apply a hand carrot to keep the left hand in a more open position, and restorative documentation stated the resident was to receive ROM to the extremities three to six days a week. The physician orders did not include documentation for ROM or a hand carrot, while the restorative aide task listed the hand carrot as a daily task. Review of the last 30 days showed the hand carrot documented eight times as non-applicable, and on two dates there was no documentation regarding application of the carrot. Restorative progress notes also documented that the resident was using a hand carrot to keep the left hand in a more open position. During observations, the resident was seen multiple times sitting in a wheelchair or in the lobby with the left hand tightly closed and no hand carrot in place. On one later observation, the hand carrot was present. Staff interviews indicated the restorative aide was the only staff member applying the hand carrot, that non-applicable was documented when the resident was asleep, and that the resident slept a lot. Administrative staff stated the restorative aide was expected to complete tasks daily and that if the resident was asleep, the resident should be re-approached when awake. The facility policy stated restorative nursing services were used to maintain and/or improve ROM, mobility, and ADL skills.
Failure to Supervise Resident with Wandering and Elopement Risk
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and adequate supervision when Resident 1, who had diagnoses including Alzheimer's disease, dementia, adjustment disorder, and anxiety, was able to exit the building without staff knowledge or supervision. The resident's admission MDS documented severely impaired cognition with a BIMS score of 3, wandering behaviors, and rejection of care. Care area assessments noted frequent wandering into other residents' rooms, inability to stop wandering, and the need for frequent monitoring and redirection. The resident also had an elopement bracelet in place and was identified in the care plan as being at risk for elopement. Behavior notes documented repeated wandering and pacing throughout the facility, including agitation when staff attempted to redirect the resident. A behavior assessment progress note documented the resident wandered in hallways and into other residents' rooms and was unable to stop wandering. Witness statements and staff interviews described the incident in which the front door alarm sounded while the resident was observed following a visitor out the front door. One staff member went to the door, looked outside, turned off the alarm, let the visitor out, and then returned inside to locate residents, after which the resident was found. Another witness statement documented that a dietary staff member saw the resident outside and assisted her back into the building. Staff interviews confirmed the resident had ongoing wandering behaviors and was often redirected by her spouse or staff. Administrative staff stated the investigation included security camera footage showing the resident following a visitor out the front door. The facility also reported that the visitor who allowed the resident to exit was Spanish-speaking only and could not read the English-only warning signage on the front doors. The facility's elopement policy stated it would provide adequate supervision and devices to deter elopement.
Medication Not Available for Ordered Administration
Penalty
Summary
The facility failed to ensure that medications were available for administration as ordered for a resident with diagnoses of dementia, psychotic disorder, and major depressive disorder. The resident’s EMR showed an order for fluvoxamine 50 mg every evening for major depressive disorder, and the MAR documented six missed doses in November 2025 because the medication was not available or had not been received. The Orders Administration Notes repeatedly documented that fluvoxamine was not available or not received on the missed-dose dates. The resident’s MDS and psychotropic drug use CAA documented intact cognition, hallucinations, delusions, minimal depression, and treatment with psychotropic medications including fluvoxamine and risperidone. During interviews, a CMA stated she would notify the charge nurse when a medication needed to be reordered, and a nurse stated CMAs should notify the nurse when a medication was not available so it could be reordered from the facility pharmacy. The Administrative Nurse stated staff were expected to order medications and that residents should receive all medications per physician orders. The facility policy stated refill medications are to be ordered five days in advance to assure an adequate supply is on hand.
Failure to Act on Pharmacist MRR Recommendations
Penalty
Summary
The facility failed to act upon the consultant pharmacist’s monthly medication regimen review (MRR) recommendations for two residents. The report stated that resident-specific MRR findings were to be documented and acted upon by the facility and/or physician, and that if recommendations were rejected, the physician was to provide a brief explanation in a dated progress note. It also stated that when recommendations were not acted upon or were rejected and there was potential for serious harm, the facility and/or consultant pharmacist should contact the Medical Director. For one resident, the EMR showed diagnoses including dementia, psychotic disorder, and major depressive disorder. The resident’s MDS and psychotropic CAA documented intact cognition, hallucinations, delusions during the look-back period, and use of psychotropic medications including fluvoxamine and risperidone. The pharmacist’s MRRs dated 02/17/25 and 04/16/25 identified medication-related concerns and recommended changes to Neurontin and Cymbalta, or documentation of benefit if no change was made. Review of the EMR did not contain the actual pharmacist report or a physician response to either recommendation. Staff interviews indicated the MRR was received by administrative nursing staff and then emailed or faxed to physicians, and that nursing staff would only see the MRR after the physician had addressed it. For the second resident, the EMR showed diagnoses of hemiparesis/hemiplegia, CVA, and depression. The resident’s MDS documented moderately impaired cognition and antidepressant use, and the psychotropic CAA noted disorganized thinking but that the resident was easily redirected. The pharmacist’s 04/16/25 MRR recommended changing Cymbalta or documenting benefit if no change was made. The physician response was not documented in the EMR until 08/27/25, four months later, when no change was ordered because the resident was wheelchair bound, cooperative, and had minimal behaviors. During observation, the resident was seated in a wheelchair with a sling and arm support in place. Interviews with nursing and administrative staff confirmed the facility expected MRRs to be returned completed and in a timely manner, and the consultant pharmacist stated he expected provider response within 30 days.
Missed Antidepressant Doses Not Reported to Physician
Penalty
Summary
The facility failed to prevent a significant medication error when R17 did not receive fluvoxamine 50 mg every evening for six consecutive days in November 2025, and the physician was not notified during that time. R17 had diagnoses of dementia, psychotic disorder, and major depressive disorder, and her records also documented hallucinations, delusions, and feelings of sadness more than half the days. Her psychotropic drug use CAA noted she was alert and oriented, able to make herself understood and understand others, and that she received fluvoxamine and risperidone with nursing monitoring for effectiveness and adverse reactions. R17’s MAR documented six missed doses of fluvoxamine, with administration notes stating the medication was not available or not received on each of those days. The behavioral health provider later documented that nursing staff had confirmed R17 was taking all medications as prescribed, but the EMR contained no evidence that the physician was notified about the missed doses. During interviews, the LN confirmed the six missed doses and stated the provider should have been notified, while the administrative nurse stated staff were expected to order medications and notify the provider when a medication was not administered. The behavioral health provider also stated she had not been notified of the missed doses and expected staff to update her on any missed medication. The facility policy required all medication errors and drug reactions to be immediately reported to the physician, DON, and the resident and/or representative.
Infection Control and PPE Use Failures During Resident Care
Penalty
Summary
The facility failed to maintain effective infection control practices for three residents, including incorrect use of PPE, lack of appropriate hand hygiene, and inadequate use of enhanced barrier precautions during high-contact care. The report also identified that contact precautions were not initiated while awaiting stool culture results for C-diff. The facility had a census of 33 residents, and 12 residents were sampled during the survey. For one resident, a one-time stool culture order that included screening for C-diff was documented in the EHR, but no culture result was found in the scanned records. During observed incontinence care, two CNAs entered the room wearing gloves and plastic gowns without performing hand hygiene first and without placing the glove cuffs over the gown sleeves. They removed blankets, lowered the bed, and cleaned stool from the resident using wipes in a manner that did not consistently use a clean portion of the wipe or obtain a new wipe when additional cleaning was needed. One CNA removed soiled wipes from between the resident’s legs, then continued care without changing gloves or performing hand hygiene before moving to the clean phase of care. During the same observation, one CNA left the room to retrieve a full-body mechanical lift after doffing PPE but did not perform hand hygiene before returning and did not don a gown when she came back. Both CNAs later removed remaining PPE without performing hand hygiene before exiting the room. In interviews, the CNAs confirmed the observed practices and stated hand hygiene should have been performed on entry, after glove removal, and after removing PPE. A licensed nurse and an administrative nurse stated that hand hygiene should occur before PPE use, after glove changes, and after PPE removal, and that the resident should have been placed under contact isolation while awaiting the C-diff culture result.
Unsafe and Unsanitary Environmental Conditions
Penalty
Summary
The facility failed to maintain a safe, sanitary environment in resident rooms, the dining room, and the activity room. During an environmental tour with Maintenance Staff U, surveyors observed that 31 of 33 resident rooms had missing ceiling tiles next to the ceiling heat vent, and ceiling tiles in hall 200 and hall 300 near the dining room and activity room were discolored. Maintenance Staff U stated the ceiling tiles in resident rooms were not in place because the heating and cooling system was old, causing the tiles to get wet, become discolored, and fall from the suspended ceiling. He also stated the facility removed the ceiling tiles so drips of water could be seen to determine whether there was a concern to address. In addition, the dishwasher temperature was observed at 80 degrees F during the survey, and Maintenance Staff U reported the plumber had connected the plumbing incorrectly to the cold piping before he fixed it and retested the temperature at 127 degrees F. The facility did not provide a policy.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Ulysses
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stanton County Health Care Facility Ltcu | 21.9 mi | ★★★★★ | 14 | 0 |
| Satanta District Hospital Ltcu | 22.2 mi | — | 0 | 0 |
| Kearny County Hospital Ltcu | 25.6 mi | ★★★★★ | 0 | 0 |
| Stevens County Hospital Ltcu Dba Pioneer Manor | 29.3 mi | ★★★★★ | 1 | 0 |
| Garden Valley Retirement Village | 37.6 mi | ★★★★★ | 0 | 0 |
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