Inspection Reports for
Prairie Estates

The complaint investigation focused on Resident #1, who had issues with dentures that did not fit, broke a tooth, and had not received timely dental care. The resident reported lack of adjustments, repairs, or replacements and unresponsiveness from the Social Worker. Interviews and record reviews confirmed failures in care planning and dental service provision. The resident was placed on a dental list but was not seen due to incomplete re-enrollment paperwork.

The facility failed to develop and implement a comprehensive care plan for Resident #1 that included measurable objectives and timeframes to meet medical, nursing, mental, psychosocial, and dental needs. The facility also failed to provide routine and 24-hour emergency dental care, resulting in Resident #1 having ill-fitting dentures, a broken tooth, and unmet dental care needs.

The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, and failed to maintain complete and accurate clinical records for one resident receiving psychotropic medications without documented diagnoses.

The facility was found deficient in multiple areas including failure to provide PASRR level 2 evaluations for residents with mental illness, failure to complete baseline care plans within 48 hours of admission, inadequate catheter care leading to resident pain and risk of infection, improper feeding tube care, improper food storage in the kitchen, incomplete clinical records for psychotropic medication use, and failure to maintain infection prevention and control protocols including PPE use.

The complaint investigation revealed that Resident #3 did not have the mental capacity to consent to receiving information from the facility affiliated insurance company. Family members reported that Resident #3's information was released without consent, leading to exploitation. A Licensed Baccalaureate Social Worker (LBSW) admitted to falsifying verbal consents on patient choice forms under pressure from previous administration and corporate to increase referrals. The Administrator and corporate officials acknowledged the issue and the need to terminate involved employees. Regarding wheelchair cleanliness, observations and interviews confirmed that wheelchairs for Resident #1 and Resident #2 were dirty and not cleaned regularly despite staff responsibility and available maintenance procedures.

The facility failed to ensure Resident #3 provided proper consent for sharing information with an affiliated insurance company, resulting in potential exploitation and violation of resident rights. Additionally, the facility failed to maintain clean and sanitary wheelchairs for Resident #1 and Resident #2, posing a risk to residents' quality of life.

The complaint involved Resident #1 missing her evening medications on 1/14/24. Resident #1 reported the medication aide came early, she declined due to nausea, and the aide did not follow up properly. The facility investigated, interviewed involved staff, and found documentation and notification failures. The physician was notified the next day, and no adverse effects were noted. The facility provided in-service training and disciplinary actions to staff involved.

The facility failed to administer evening medications to Resident #1 when she requested to take them later and failed to document the missed doses or notify the physician. Interviews and record reviews confirmed the medication aide did not follow up appropriately, and documentation of refusal was absent or unclear. The facility conducted in-service training and disciplinary actions following the incident.

The facility was found deficient in providing adequate personal care to a resident, maintaining food safety standards in the kitchen, and properly disposing of garbage and refuse. Specific issues included failure to groom a resident's hair, unsanitary conditions in the kitchen including an unclean ice machine and microwave, and improperly contained trash in the dumpster area.

The complaint investigation focused on Resident #1, who was enrolled in hospice with a Full Code status. The facility failed to initiate CPR when Resident #1 was found unresponsive, violating the resident's advance directives. An Immediate Jeopardy was identified and later removed after corrective actions including staff education, audits, and policy reinforcement.

The facility failed to develop a comprehensive person-centered care plan for Resident #1, specifically failing to include Full Code advanced directives. Additionally, the facility failed to provide CPR to Resident #1 when found unresponsive despite a Full Code status, resulting in immediate jeopardy that was later removed after corrective actions. The facility implemented education, audits, and monitoring to prevent recurrence.

The investigation was complaint-related, focusing on failure to update care plans after incidents and failure to provide appropriate respiratory care. Substantiation status is not explicitly stated.

The facility failed to ensure that Resident #2's care plan was reviewed and updated quarterly to reflect recent falls, and failed to ensure that Resident #1's oxygen concentrator humidifier was properly serviced, risking inadequate respiratory care.

The facility failed to develop and implement comprehensive, person-centered care plans for residents with mental health diagnoses, failed to revise care plans after incidents such as elopement, and failed to secure unused or expired medications properly. These deficiencies posed risks to individualized resident care and medication safety.