Inspection Reports for
Prairie Gate

The complaint involved Resident #1 who reported rough treatment by a female overnight staff member. The resident and her daughter reported bruising and concerns about staff roughness. The facility failed to report the suspected abuse to the State Agency and did not conduct a proper investigation or assessment. The resident passed away during the investigation period.

The facility failed to report an incident of possible physical abuse to the appropriate entity and failed to investigate an allegation of abuse for Resident #1. Resident #1 had multiple bruises related to a fall and reported rough treatment by a female overnight staff member. Staff and family interviews revealed concerns about staff roughness, but no formal reports or assessments were completed. The facility did not complete an assessment related to the resident's reports of rough treatment, and no abuse report was made to the State Agency.

The visit was complaint-related due to a fall incident involving Resident #135. The complaint was substantiated as the facility failed to ensure proper transfer procedures, leading to the resident falling out of the wheelchair and sustaining injuries.

The facility failed to protect Resident #135 from accidents and injuries when staff did not place the resident's feet on the wheelchair foot pedals during transfer, resulting in a fall and injury. The Administrator and Director of Nursing confirmed the staff did not follow proper transfer procedures.

The facility failed to protect residents from accidents and injuries during wheelchair transfers and did not fully adhere to infection prevention protocols during catheter care, resulting in minimal harm or potential for harm to a few residents.

The complaint involved Resident #4 reporting rough treatment by an overnight Certified Nursing Assistant (CNA) who pulled on her arm causing pain. The facility investigated and identified the staff member, who was an agency CNA and was subsequently removed from the facility. Resident #4 expressed concern for other residents who could not speak up. The complaint was substantiated with minimal harm.

The facility failed to treat Resident #4 with dignity and respect during personal care, with evidence of rough handling by a staff member causing pain to the resident's previously injured arm. Additionally, the facility failed to properly monitor an alarmed door after Resident #1 eloped from the care center.

The investigation was complaint-driven, focusing on allegations of rough handling by Staff A, failure to allow a resident to refuse care, and inadequate staff response to call lights. Substantiation is implied by the findings but not explicitly stated.

The facility failed to ensure residents were treated with dignity and respect, including rough handling during transfers by Staff A and failure to allow a resident to refuse care. Additionally, the facility failed to provide adequate nursing staff to respond to call lights in a timely manner, impacting resident safety.

The visit was complaint-related due to allegations of rough handling of residents, failure to respect resident rights including refusal of care, and concerns about staff responsiveness and safety practices.

The facility failed to ensure dignified care and resident rights for multiple residents, including rough handling during transfers and refusal of care. Additional findings included failure to maintain a safe environment, inaccurate resident assessments, unsafe respiratory care, inadequate nursing staff response to call lights, failure to post nurse staffing information properly, and improper food storage practices.

The survey identified multiple deficiencies including issues with medication management policies, baseline tuberculosis screening, food service policies, service plans lacking measurable goals and objectives, and resident activity goals. The facility failed to comply with several regulatory requirements related to medication administration, tuberculosis testing, food handling training, service planning, and resident activities.

The complaint investigation focused on medication errors related to Resident #1's Bumetanide orders. The facility failed to implement the correct dosing orders, resulting in the resident receiving excessive medication doses for approximately 58 days. This led to an acute kidney injury and hospitalization. The facility was notified of immediate jeopardy which was removed after corrective actions were implemented.

The facility failed to clarify discrepancies in physician orders and transcribe medication orders correctly for Resident #1, leading to significant medication errors with Bumetanide dosing. Resident #1 received incorrect dosages over an extended period, resulting in an acute kidney injury and hospitalization. The facility implemented corrective actions including staff education and order auditing.

The complaint investigation found that the facility failed to implement timely treatment orders for a pressure ulcer on Resident #1's heel, with treatment orders delayed until 2/27/24 despite ulcer discovery on 2/21/24. The ulcer worsened due to lack of daily wound monitoring and incomplete documentation.

The facility failed to timely obtain and implement physician treatment orders for a pressure ulcer on Resident #1's heel, resulting in actual harm. Documentation and daily wound monitoring were lacking, and staff were unaware of the ulcer until several days after its discovery.

The facility failed to timely update care plans to reflect changes in residents' conditions, delayed implementation of treatment orders for pressure ulcers, and served food at unsafe temperatures to multiple residents. Several residents experienced minimal to actual harm due to these deficiencies.

The facility failed to complete comprehensive assessments for Resident #4 prior to hospitalization and upon return, and failed to ensure Resident #2's personal refrigerator was checked daily for safe storage of items, including alcohol. Both deficiencies were found to have minimal harm with few residents affected.