Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Prairie Maison during CMS and state inspections, most recent first.
A resident with hemiplegia, dysphagia, generalized weakness, and Lewy body dementia had a 10-lb weight loss in one week while on a mechanically altered diet and dependent for eating. The weight change was documented, but no provider notification was recorded. Staff interviews showed inconsistent understanding of when to notify the provider, and the DON stated she was not aware of the resident’s weight loss.
A resident with multiple diagnoses including dementia, hemiplegia, and impaired cognition had repeated falls, but several fall reports did not document a root cause as required by facility policy. The resident’s care plan was not updated after several falls to add new fall-prevention interventions, and it still listed a motion sensor alarm that staff said had been removed and was not observed in the room. Staff interviews showed inconsistent understanding of the resident’s current fall interventions.
A resident with Type II DM and diabetic CKD was treated with Cefdinir for a UTI even though the facility's infection control line list showed the resident's symptoms did not meet McGeer's criteria. The QA RN/infection preventionist confirmed the criteria were not met and had no evidence that a provider was notified that the resident was being treated without meeting UTI infection criteria.
The facility did not report multiple allegations of abuse, neglect, or mistreatment—including a resident allegedly viewing child pornography, staff yelling at a resident, discouraging call light use, and withholding pain medication—to the State Survey Agency or law enforcement as required by policy. The Nursing Home Administrator confirmed awareness of these incidents but acknowledged they were not reported.
The facility did not thoroughly investigate several allegations of abuse and neglect, including accusations of inappropriate resident behavior, staff yelling at a resident, discouraging call light use, and withholding pain medication. Investigations were incomplete, lacking staff and resident interviews, safety assessments, and follow-up, contrary to facility policy.
The facility failed to assess the risk of entrapment between mattresses and side rails for residents, leading to a resident injury. No alternative measures were attempted before installing side rails, and assessments were incomplete. This deficiency affected multiple residents, particularly those using air mattresses, increasing the risk of entrapment.
A resident with a history of weakness and vision issues sustained burns after spilling hot coffee on herself in an LTC facility. The coffee was served at a temperature above safe levels, and the resident's care plan did not initially include a lid on hot liquids. Staff interviews revealed that coffee temperatures were not routinely checked, and there was inconsistent signage regarding adding ice to hot beverages. The facility's failure to implement adequate safety measures and supervision contributed to the incident.
The facility failed to implement adequate fall prevention measures for two residents at high risk for falls. One resident, with a history of falls and fractures, did not have a fall care plan or interventions initiated upon admission or after a fall, resulting in a serious femur fracture. Another resident, with moderate cognitive impairment, experienced a fall due to staff not following care plan interventions, such as keeping the bed in the lowest position. Staff interviews confirmed the lack of necessary interventions and care plan updates.
The facility failed to create comprehensive care plans for residents on psychotropic medications, lacking individualized targeted behaviors and non-pharmacological interventions. Residents were prescribed medications like antipsychotics, antidepressants, and sleep aids, but their care plans did not address specific behaviors or conditions such as anxiety, depression, and insomnia. Interviews with staff confirmed the expectation for care plans to include these details.
The facility failed to ensure proper management of psychotropic medications for residents, as evidenced by the lack of individualized behavior monitoring, non-pharmacological interventions, and sleep assessments. Residents were prescribed these medications without necessary documentation or appropriate diagnoses, leading to deficiencies in care planning and monitoring.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to immediately notify the physician when R32 had a significant weight loss that required possible alteration of treatment. R32, who had diagnoses including hemiplegia and hemiparesis following a nontraumatic intracranial hemorrhage, dysphagia, generalized muscle weakness, and neurocognitive disorder with Lewy bodies, was dependent on staff for eating and received a mechanically altered diet. The physician order required weekly weights, and the weight record showed R32 weighed 112.2 lbs. on 7/8/25 and 102.2 lbs. on 7/15/25, a 10-pound loss in one week, with no documented notification to the provider. The facility policies stated that physicians should be informed immediately of a resident change of condition and that residents with significant weight changes should be reweighed and the primary care provider, family, and dietitian notified of unplanned significant weight changes. During interviews, an LPN stated that provider notification would occur for a 5-pound change or per physician order, another LPN stated she would follow the physician order, and an NP stated she would have expected to be notified of the 10-pound loss over one week. The DON stated the facility uses Interact for change of condition and said she would expect staff to reweigh the resident and notify the physician if the weight was accurate, but she was not aware of R32's weight loss.
Incomplete fall documentation and outdated care plan interventions
Penalty
Summary
The facility did not ensure the environment was free of accident hazards and did not provide adequate supervision to prevent accidents for one resident with repeated falls. The resident had diagnoses including hemiplegia and hemiparesis following intracerebral hemorrhage, metabolic encephalopathy, Alzheimer’s disease with late onset, chronic kidney disease, depression, insomnia, and dementia. The resident’s MDS assessment showed a BIMS score of 12 out of 15, indicating moderately impaired cognition. The resident experienced multiple falls after admission, including falls on 5/1/25, 5/8/25, 5/14/25, 5/20/25, 5/21/25, 5/23/25, 5/25/25, 5/26/25, 5/28/25, 5/29/25, 6/6/25, 7/13/25, and 7/25/25. The facility’s fall reports did not document a root cause for several of the resident’s falls, despite the facility policy requiring a risk management and root cause analysis whenever a resident falls. The reports for falls on 5/1/25, 5/8/25, 5/25/25, 5/26/25, 5/28/25, and 6/6/25 lacked documented root causes. Survey review also found that the resident’s comprehensive care plan was not updated after several falls, including falls on 5/20/25, 5/28/25, 5/29/25, and 7/25/25, to add interventions intended to prevent future falls. The care plan included multiple fall-related interventions such as a low bed, floor mats, Dycem in the chair, a bulb call light, a night light, bumpers on the mattress, and a motion sensor alarm. Survey observations and staff interviews showed inconsistencies between the care plan and the resident’s actual room setup. A motion sensor was listed on the care plan as an intervention initiated on 6/9/25, but surveyors did not observe one in the room, and staff gave conflicting responses about whether it was in place. The DON stated the motion sensor had been tried but removed because it did not work, and no documentation was available showing when or why it was discontinued. The care plan still contained the discontinued motion sensor intervention, and after the 6/6/25 fall the facility did not replace it with another intervention. The DON also stated care plans should be updated after every fall, but the record did not show that occurring for all of the resident’s falls.
Antibiotic Used Without Meeting UTI Criteria
Penalty
Summary
The facility did not ensure its antibiotic stewardship program was followed for one supplemented resident, R16, who was treated with an antibiotic for a UTI without appropriate indications for use. The facility policy stated that nurses were to use McGeer's constitutional infection criteria to determine whether antibiotic treatment was necessary and, if a physician ordered an antibiotic without identified infection criteria, the physician was to be asked to provide the rationale and the Medical Director contacted for further direction. R16, who was admitted with diagnoses including Type II DM with diabetic CKD, was listed on the facility's June 2025 infection control line list for a UTI. The line list documented nausea, dizziness, vomiting, and elevated blood pressures, noted that a culture was obtained, and showed treatment with Cefdinir, while also indicating that infection criteria were not met. During interview, the QA RN who also served as the infection preventionist stated that McGeer's criteria were used at the facility and acknowledged that R16's symptoms did not meet those criteria. She also stated there was no evidence that a provider was notified that R16 did not meet criteria while being treated for a UTI.
Failure to Report Alleged Abuse and Neglect to Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and appropriate authorities, including the State Survey Agency and law enforcement, as required by policy and state law. Specifically, for five of six residents reviewed, allegations and grievances related to abuse or neglect were not reported as mandated. These included an allegation that one resident was watching child pornography and offered to show it to another resident, a report of a staff member yelling at a resident in the dining room, a staff member telling a resident not to use her call light excessively, and a complaint that a nurse did not provide a pain pill as requested. In each instance, the facility's grievance log documented the concerns, but there was no evidence that these incidents were reported to the required agencies. Interviews with the Nursing Home Administrator confirmed awareness of at least some of these allegations but acknowledged that they were not reported as required. The facility's own policy states that any suspicion of abuse, neglect, exploitation, or misappropriation must be reported immediately to the administrator and appropriate authorities. Despite this, the incidents involving the residents were not communicated to the State Survey Agency or law enforcement, constituting a failure to follow established procedures for reporting suspected abuse or neglect.
Failure to Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse involving five residents. In one instance, a resident accused another of watching child pornography, but the facility did not conduct an investigation into the allegation, as confirmed by the Nursing Home Administrator. Other incidents included a resident reporting that a staff member yelled at another resident in the dining room, a resident being told by staff not to use her call light as much, and a resident stating that a nurse did not provide her with a pain pill as requested. In each of these cases, the facility's investigations were incomplete, lacking interviews with involved staff or other residents, assessments to ensure resident safety, and follow-up with the residents who made the allegations. The facility's own policy requires that all allegations of abuse, neglect, exploitation, or misappropriation be thoroughly investigated, with the administrator initiating the investigation process. However, the survey found that the facility did not adhere to this policy, as evidenced by the lack of comprehensive investigations, absence of protective measures, and failure to notify authorities or conduct follow-up. The Nursing Home Administrator acknowledged that grievances and allegations should be fully investigated according to policy, but this was not done in the reviewed cases.
Failure to Assess Bed Rail Safety Risks
Penalty
Summary
The facility failed to implement a system to assess the risk of entrapment between the mattress and side rails for residents using bed rails or enabler bars. This deficiency was observed in 16 out of 22 residents with standard mattresses and 6 out of 22 residents using air mattresses. The facility did not attempt alternative measures before installing side rails, nor did it conduct thorough assessments to identify potential entrapment risks, particularly with air mattresses that increase the risk of entrapment. One resident, who was admitted with diagnoses including diabetes, neuropathy, and hypertensive heart disease, was found with a large bruise on the neck, which the facility concluded was caused by the bed rail. Despite this incident, no new interventions were implemented, and the resident's bed rail assessment was incomplete. The facility did not attempt alternative solutions before installing the bed rails, nor did it assess the gaps between the air mattress and bed rails, which could pose a risk of entrapment. The facility's policy required regular bed inspections and individual bed rail evaluations, but these were not conducted as needed. Maintenance staff installed bed rails without assessing potential entrapment risks, and there was no documentation of alternatives being tried before installation. The facility's failure to assess and monitor bed rail safety contributed to the immediate jeopardy finding when a resident was injured by a bed rail.
Resident Burned by Hot Coffee Due to Inadequate Safety Measures
Penalty
Summary
The facility failed to ensure a safe environment for a resident, R10, who sustained first and second-degree burns after spilling hot coffee on herself. R10, who has a history of weakness, hemiplegia, hemiparesis, and cataracts, was admitted to the facility with specific dietary needs, including a fluid restriction and adaptive equipment for meals. However, her care plan did not initially include a lid on hot liquids, which was only added after the incident was brought to the attention of the Director of Nursing (DON). The incident occurred when R10 spilled coffee on her lap, resulting in burns that required emergency room evaluation. The coffee temperature was found to be 165.4 degrees, which is above the threshold that can cause third-degree burns in one second. Despite the facility's policy on food safety, which mandates serving hot beverages at safe temperatures and monitoring them at the point of service, the staff did not check the coffee temperature regularly. Interviews with staff revealed that the coffee temperature was not routinely monitored, and there was no signage on R10's unit to instruct staff to add ice to hot beverages. The surveyor's observations confirmed that the coffee machine was accessible to residents, and the coffee temperatures on both units were consistently above safe levels. The facility's failure to implement adequate supervision and safety measures, such as ensuring lids on hot beverages and monitoring temperatures, directly contributed to the accident. The lack of consistent signage and staff awareness further exacerbated the risk of burns from hot liquids, as evidenced by the incident involving R10.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent falls for two residents, R38 and R11, who were at high risk for falls. R38, with a history of falls and fractures, was admitted with multiple diagnoses including difficulty in walking and dementia. Despite a fall risk score indicating high risk, the facility did not initiate a fall care plan or interventions upon admission or after R38's fall on 5/10/24. This lack of action resulted in another fall on 5/31/24, leading to a serious femur fracture requiring surgical intervention. R11, who was moderately cognitively impaired, also experienced a fall resulting in a pelvic fracture. The facility's failure to ensure staff followed the care plan interventions, such as keeping the bed in the lowest position, contributed to this incident. Observations revealed that the bed was not consistently kept in the lowest position, and staff were unaware of this intervention, indicating a lack of communication and adherence to the care plan. The facility's policies on fall prevention and care planning were not effectively implemented, as evidenced by the absence of a root cause analysis and updated care plans following falls. Interviews with staff, including the LPN and DON, confirmed that necessary interventions and care plans were not in place or updated as required, highlighting a systemic issue in managing fall risks and ensuring resident safety.
Deficient Care Planning for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for five residents who were reviewed for unnecessary medications. These residents were prescribed various psychotropic medications, including antipsychotics, antidepressants, and sleep aids, but their care plans did not address individualized targeted behaviors or non-pharmacological interventions. For instance, one resident was taking Quetiapine for anxiety and Levetiracetam for seizures, yet their care plan did not include targeted behaviors for the antipsychotic or interventions for anxiety and seizures. Another resident was prescribed Nortriptyline and Sertraline for depression and Melatonin for insomnia, but their care plan lacked specific behaviors for the antidepressant use and did not address insomnia. Similarly, a third resident's care plan did not include individualized behaviors or interventions for anxiety despite being on Escitalopram and Melatonin. The care plan only mentioned monitoring for general symptoms without addressing the resident's insomnia. Additionally, a resident receiving Remeron for appetite stimulation and depression did not have a care plan reflecting its use for these purposes. The CNA Kardex also lacked information on monitoring psychotropic medications. Interviews with facility staff, including an LPN and the DON, confirmed that care plans should include individualized behaviors and non-pharmacological interventions, and that these should be reflected in the Kardex for CNAs to report appropriately.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified for five residents who were reviewed for unnecessary medications. The facility's policy on psychotropic medication use was not adhered to, as residents were prescribed these medications without individualized behavior monitoring or non-pharmacological interventions being utilized. Additionally, there was a lack of documentation for sleep assessments or monitoring for residents receiving medication for insomnia. One resident, admitted with diagnoses including Parkinson's Disease, Insomnia, and Major Depressive Disorder, was taking antidepressants and melatonin without any documentation of individualized targeted behaviors or sleep assessments. Interviews with facility staff revealed that there was no monitoring of specific behaviors related to the resident's antidepressant use, and the care plan was not individualized. Another resident, with diagnoses including stroke and anxiety disorder, was receiving psychotropic medication without documentation of individualized behaviors or sleep monitoring, despite staff being aware of the resident's anxiety triggers. Further examples include a resident with epilepsy and anxiety disorder who was prescribed an antipsychotic without an appropriate diagnosis or indication of use. Another resident was taking multiple antidepressants and a sleep aid without documentation of behavior monitoring or non-pharmacological interventions. Lastly, a resident receiving Remeron for appetite stimulation and depression did not have a care plan for depression, and there was no documentation of targeted behaviors. Interviews with staff indicated a lack of awareness and documentation regarding the monitoring of behaviors and the efficacy of medications.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Prairie Du Chien
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Great River Care Center | 3.3 mi | ★★★★★ | 2 | 1 |
| Guttenberg Care Center | 18.3 mi | ★★★★★ | 1 | 0 |
| Elkader Care Center | 19.3 mi | ★★★★★ | 0 | 0 |
| Care And Rehab - Boscobel | 22.3 mi | ★★★★★ | 0 | 0 |
| Thornton Manor Nursing And Care Center | 22.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.