Inspection Reports for Prairie Gate
16 Valley View Dr, Council Bluffs, IA 51503, IA, 51503
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Inspection Report
Plan of Correction
Deficiencies: 1
Dec 29, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction following a credible allegation of substantial compliance and Plan of Correction.
Findings
Based on acceptance of the credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective December 19, 2025.
Deficiencies (1)
| Description |
|---|
| Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction. |
Report Facts
Certification effective date: Dec 19, 2025
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 4
Oct 9, 2025
Visit Reason
The inspection was conducted as a result of complaint #2569359-C alleging possible physical abuse of a resident at the facility.
Findings
The facility failed to report an incident of possible physical abuse involving Resident #1 to the appropriate entity within the required timeframe and failed to investigate the allegation thoroughly. The facility also failed to complete an assessment related to bruising reported during care.
Complaint Details
Complaint #2569359-C was substantiated as the facility was found deficient in reporting and investigating alleged abuse of Resident #1.
Severity Breakdown
SS = D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to report alleged abuse involving Resident #1 within required timeframes. | SS = D |
| Failure to investigate allegations of abuse thoroughly and prevent further potential abuse during investigation. | SS = D |
| Failure to complete assessment related to bruising reported during care for Resident #1. | SS = D |
| Failure to ensure quality of care related to bruising and assessment for Resident #1. | SS = D |
Report Facts
Census: 34
Residents reviewed: 1
BIMS score: 15
BIMS score: 8
Audit frequency: 5
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | RN Clinical Coordinator | Explained Resident #1 had passed away and discussed staff roughness concerns |
| Staff B | Licensed Practical Nurse (LPN) | Spoke with Resident #1's daughter about bruises and staff interactions |
| Staff A | Registered Nurse (RN) | Acknowledged bruising on Resident #1 and staff roughness reports |
| Staff F | Certified Nursing Assistant (CNA) | Completed assessment on Resident #1 and discussed reporting procedures |
| Staff D | Previous Director of Nursing (DON) | Discussed reporting and investigation of abuse allegations |
| Administrator | Facility Administrator | Acknowledged no prior report of abuse and described reporting procedures |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 11, 2025
Visit Reason
The document is a plan of correction submitted by the facility following a prior inspection, indicating acceptance of substantial compliance and outlining corrective actions.
Findings
The facility has accepted the allegation of substantial compliance and submitted a plan of correction, with certification of compliance effective August 7, 2025.
Deficiencies (1)
| Description |
|---|
| Initial comments regarding acceptance of substantial compliance and plan of correction. |
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 2
Jul 9, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of a facility-reported incident involving a resident fall.
Findings
The survey identified deficiencies related to accident hazards and supervision resulting in a resident fall from a wheelchair, and infection prevention and control failures related to catheter care and hand hygiene practices.
Severity Breakdown
SS = D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to protect residents from accidents and injuries, evidenced by a resident falling out of a wheelchair during transfer. | SS = D |
| Facility failed to establish and maintain an infection prevention and control program, specifically failing to provide appropriate infection prevention practices during catheter care. | SS = D |
Report Facts
Resident census: 33
Urine volume emptied: 450
BIMS score: 4
BIMS score: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Named in the finding related to resident fall from wheelchair |
| Staff B | Certified Nursing Assistant | Named in the finding related to improper catheter care and hand hygiene |
| Administrator | Administrator | Provided statements confirming details of resident fall incident |
| Director of Nursing | Director of Nursing | Provided statements regarding expectations for resident transfers and catheter care |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 22, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective June 22, 2025.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
May 23, 2025
Visit Reason
The inspection was conducted based on investigations of facility reported incidents #126017-I and #127463-I and a facility reported incident #128725-M, including a complaint (#126017-I) that resulted in a deficiency.
Findings
The facility failed to treat Resident #4 with dignity and respect during personal care, as evidenced by rough handling by a staff member causing pain and distress. Additionally, the facility failed to properly check an alarmed door after Resident #1 exited the care center, posing a safety risk.
Complaint Details
Complaint #126017-I was substantiated, resulting in a deficiency related to the rough handling of Resident #4 by an overnight staff member (Staff B). The investigation included interviews with residents, family, and staff, and led to the removal of the agency CNA from the facility. The complaint also involved failure to properly monitor an alarmed door leading to Resident #1 eloping from the unit.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to treat Resident #4 with dignity and respect during personal care, including rough handling causing pain and distress. | SS=D |
| Failure to ensure the resident environment remains free of accident hazards and provide adequate supervision to prevent accidents, as evidenced by failure to properly check an alarmed door after Resident #1 exited the care center. | SS=D |
Report Facts
Deficiencies cited: 2
Resident census: 35
BIMS score: 15
BIMS score: 5
Distance: 62
Time of elopement: 1931
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Agency Certified Nursing Assistant (CNA) | Named in rough handling and dignity violation of Resident #4 |
| Staff C | Registered Nurse (RN) | Completed body audit and assessment of Resident #4 after incident |
| Staff A | Clinical Coordinator | Reported Resident #4's daughter's complaint and investigation details |
| Staff D | Certified Nursing Assistant (CNA) | Assisted Resident #4 after incident and reported observations |
| Staff E | Certified Nursing Assistant (CNA) | Provided care to Resident #4 the morning after the incident and reported resident's distress |
| Staff F | Cook/Chef | Failed to properly respond to door alarm leading to Resident #1 elopement |
| Administrator | Facility Administrator | Provided statements regarding staff conduct and door alarm protocol |
| Director of Nursing | Director of Nursing (DON) | Involved in investigation and decision to remove Staff B |
| Resident Services Director | Resident Services Director | Reported Resident #4's shoulder soreness and incident details |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 15, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective September 15, 2024.
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 8
Aug 15, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of multiple complaints and facility reported incidents.
Findings
The facility was found deficient in multiple areas including failure to provide care in a dignified manner, failure to allow residents to exercise rights, failure to maintain a safe and comfortable environment, inaccurate resident assessments, unsafe transfer techniques, inadequate respiratory care, insufficient nursing staff response to call lights, failure to post nurse staffing information properly, and improper food storage practices.
Complaint Details
Complaints #122625-C, #122654-C, #122735-C and facility reported incidents #122620-I, #122703-I were substantiated.
Severity Breakdown
F 550: 1
F 584: 1
F 641: 1
F 689: 1
F 695: 1
F 725: 1
F 732: 1
F 812: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure care was provided in a dignified manner for 3 residents and failure to ensure residents could refuse care for 1 resident. | F 550 |
| Failure to maintain a safe, clean, comfortable, and homelike environment by not changing bed linen for 1 resident. | F 584 |
| Failure to complete an accurate assessment reflecting resident's status for 1 resident. | F 641 |
| Failure to ensure safe transfer techniques for 1 resident, including transferring without gait belt and alone when 2 staff were required. | F 689 |
| Failure to provide respiratory care consistent with professional standards for 1 resident requiring oxygen, including failure to change and date oxygen tubing weekly. | F 695 |
| Failure to provide sufficient nursing staff to respond to call lights in a timely manner for 4 residents. | F 725 |
| Failure to post nurse staffing data daily in a prominent place accessible to residents and visitors. | F 732 |
| Failure to ensure food was stored according to safe practices, including undated open containers and improper storage of raw chicken above fresh foods. | F 812 |
Report Facts
Residents reviewed for dignity: 14
Residents reviewed for rights: 3
Facility census: 32
Call light response times: 80
Call light response times: 63
Call light response times: 34
Call light response times: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Named in multiple findings related to rough transfers, failure to use gait belt, and disciplinary actions |
| Staff B | Registered Nurse | Expressed concerns about Staff A's transfer techniques |
| Staff C | Certified Nurse Aide | Reported residents did not want Staff A to care for them |
| Staff D | Certified Nurse Aide | Reported Staff A was rough and in a hurry during transfers |
| Staff E | Certified Nurse Aide | Reported residents asked Staff A to slow down |
| Staff F | Scheduling Staff | Reported nurse staffing data was not posted in a location accessible to residents |
| Staff G | Certified Nurse Aide | Reported bed linens were not changed as scheduled |
| Staff H | Certified Nurse Aide | Reported not changing bedding on certain shifts |
| Staff I | Registered Nurse | Discussed oxygen tubing change procedures and shower incident |
| Staff J | Certified Nurse Assistant | Involved in shower incident with Resident #17 |
| Staff K | Registered Nurse | Discussed oxygen supply change schedule |
| Staff L | Registered Nurse | Discussed oxygen tubing change procedures |
| Staff M | Nurse | Reported oxygen tubing changed only if soiled |
| Staff N | Registered Nurse | Reported oxygen tubing changed per doctor's orders or if soiled |
| Clinical Administrator | Responsible for auditing care plans, staff education, and ensuring compliance with corrective actions | |
| Director of Nursing (DON) | Provided statements on MDS coding, call light response expectations, oxygen tubing change policy, and staffing postings | |
| Dietary Manager | Acknowledged undated food items and staff expectations for dating food |
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 21, 2024
Visit Reason
A revisit of the survey ending June 5, 2024 along with investigations of facility reported incident #122154-I was conducted on July 20-21, 2024.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective June 26, 2024. The facility reported incident #122154-I was not substantiated.
Complaint Details
Facility reported incident #122154-I was not substantiated.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Jun 5, 2024
Visit Reason
Investigation of complaint #120420-C and facility reported incident #121113-I conducted from May 30, 2024 through June 5, 2024.
Findings
The facility failed to follow physician's orders for Resident #1, resulting in a significant medication error involving incorrect dosing of Bumetanide, which contributed to an acute kidney injury. Additionally, the facility failed to ensure one nurse maintained proper licensure for the State of Iowa.
Complaint Details
Complaint #120420-C was substantiated. Facility reported incident #121113-I was substantiated.
Severity Breakdown
SS=J: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow physician's orders resulting in significant medication error for Resident #1 related to Bumetanide dosing. | SS=J |
| Failure to ensure licensed nurse had appropriate state licensure for Iowa. | SS=E |
Report Facts
Resident census: 32
Days resident received incorrect Bumetanide dose: 58
Fine amount: 8000
Bumetanide dosing orders: 2
Bumetanide dosing orders: 1
Bumetanide dosing received: 5
Weight loss: 15.4
Potassium level: 6.5
BUN level: 67
Creatinine level: 1.43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in licensure deficiency for having only a Nebraska single state license instead of Iowa multistate license |
| Staff B | Registered Nurse (RN) | Named in medication order clarification and signing after-visit summaries |
| Staff C | Clinical Coordinator | Named in medication order clarification and investigation |
| Staff D | Registered Nurse (RN) | Named in medication order clarification and signing after-visit summaries |
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 22, 2024
Visit Reason
A revisit of the survey ending February 29, 2024 was conducted to verify correction of previously cited deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities effective March 27, 2024.
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 3
Feb 29, 2024
Visit Reason
The inspection was conducted as a recertification survey and investigation of facility reported incident #119099-I and complaint #119234-C between February 26 and February 29, 2024.
Findings
The facility was found deficient in failing to review and revise care plans to reflect residents' current status, specifically for Resident #22, and failing to implement timely interventions to prevent worsening of a pressure ulcer for Resident #1. Additionally, the facility failed to provide food at an appetizing temperature to multiple residents.
Complaint Details
The visit was triggered by complaint #119234-C and facility reported incident #119099-I. Both were found to be unsubstantiated, but deficiencies were cited related to care plan management and pressure ulcer treatment.
Severity Breakdown
SS=G: 1
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to review and revise the care plan to reflect Resident #22's current status including changes in weight bearing, compression device use, and pressure injury prevention. | — |
| Failed to implement timely treatment orders and daily monitoring for a pressure ulcer on Resident #1's heel, resulting in worsening of the wound. | SS=G |
| Failed to provide food at an appetizing temperature to 5 of 18 residents reviewed, with multiple complaints of cold food and failure of kitchen equipment to maintain proper food temperatures. | SS=E |
Report Facts
Census: 29
Deficiencies cited: 3
Temperature: 80
Temperature: 128
Temperature: 135
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Interim Clinical Administrator and Clinical Coordinator | Provided statements regarding care plan management and acknowledged concerns about meal service |
| Staff I | Physical Therapist Assistant (PTA)/Director of Rehabilitation (DOR) | Provided information about Resident #22's weight bearing status changes |
| Staff A | Licensed Practical Nurse (LPN) | Prepared treatment for Resident #1's pressure ulcer and was unaware of heel wound initially |
| Staff C | Registered Nurse (RN) | Assessed Resident #1's heel pain and coordinated with DON for treatment orders |
| Staff K | Dietary Staff | Reported complaints about cold food and measured waffle temperature |
| Staff L | Certified Dietary Manager | Acknowledged ongoing issues with food temperature and kitchen equipment |
| Staff B | Certified Nursing Assistant (CNA) | Reported frequent complaints of cold food and described resident concerns |
| Staff H | Certified Dietary Manager | Explained expectations for steam table temperature and issues maintaining food temperature |
| Staff G | Dietary Cook | Observed food not being held at proper temperature |
| Administrator | Facility Administrator | Acknowledged expectations for food temperature and resident complaints |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 22, 2023
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective September 22, 2023, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 2
Sep 14, 2023
Visit Reason
The inspection was conducted as a result of investigations into complaints #111488-C, #111608-C, #111841-C, and #111993-C between September 5, 2023 and September 14, 2023.
Findings
The facility was found to be in compliance with COVID-19 infection control practices. However, deficiencies were identified related to quality of care, including failure to complete comprehensive assessments prior to hospitalization and upon return, and failure to ensure safe storage of resident personal food items such as alcohol. Some complaints were substantiated while others were not.
Complaint Details
Complaints #111488-C and #111993-C were not substantiated. Complaint #111608-C was substantiated. Complaint #111841-C was substantiated but did not result in a deficiency.
Deficiencies (2)
| Description |
|---|
| Failure to complete a comprehensive assessment prior to hospitalization and upon return for Resident #4. |
| Failure to ensure resident's personal refrigerator was checked daily to ensure safe storage of food items, including an unopened bottle of wine in Resident #2's refrigerator. |
Report Facts
Total Residents: 22
Brief Interview of Mental Status (BIMS) score: 11
Brief Interview of Mental Status (BIMS) score: 15
Lab result BUN: 93
Lab result creatinine: 1.06
Alcohol allowance: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Jaskey | Campus Administrator | Signed the plan of correction and involved in education of staff regarding deficiencies |
| Clinical Administrator | Involved in monitoring and education related to deficiencies; no full name provided | |
| Staff A Registered Nurse | Provided statements regarding resident assessments and alcohol storage; no full name provided | |
| Clinical Coordinator | Provided statements regarding alcohol storage and removal from resident refrigerator; no full name provided |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 13, 2023
Visit Reason
A revisit of the survey ending November 1, 2022 was conducted on January 12-13, 2023 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective December 9, 2022.
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 7
Nov 1, 2022
Visit Reason
The inspection was conducted as an annual health survey and investigation of complaint #105309-C from October 24 to November 1, 2022.
Findings
The facility failed to ensure residents' Iowa Physician Orders for Scope of Treatment (IPOST) medical orders were properly signed and documented, and failed to post grievance policy information and grievance officer contact details. Additional deficiencies included failure to train staff on dependent adult abuse, incomplete comprehensive care plans, lack of CPR certification for staff, inadequate food safety practices, and incomplete COVID-19 vaccination documentation for staff.
Complaint Details
Complaint #105309-C was investigated and found not substantiated.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure residents' Iowa Physician Orders for Scope of Treatment (IPOST) medical orders were signed by resident or legal representative. |
| Facility failed to post grievance policy and grievance officer contact information in a prominent location. |
| Staff member lacked documentation of Dependent Adult Abuse Mandatory Reporter training within 6 months of hire. |
| Facility failed to develop and implement comprehensive person-centered care plans for residents. |
| Facility failed to ensure CPR certification for staff on duty during shifts reviewed. |
| Facility failed to maintain proper food safety practices including temperature monitoring and food labeling. |
| Facility failed to document staff COVID-19 vaccination status and exemptions for all staff. |
Report Facts
Residents reviewed for advanced directives: 16
Residents reviewed for care plans: 10
Staff shifts reviewed for CPR certification: 20
Self-reported incidents reviewed: 5
Residents with full code status: 3
Residents on regular textured diet: 14
Residents on mechanical soft/dysphagia diet: 1
Residents with skin wounds reviewed: 4
Residents with psychotropic medication review: 5
Residents with COVID-19 vaccination exemptions: 4
Residents census: 16
Inspection Report
Complaint Investigation
Deficiencies: 0
May 5, 2021
Visit Reason
The inspection was conducted to investigate complaint 97176-C and facility reported incident 97214-I.
Findings
The complaint and reported incident were investigated and found to be not substantiated.
Complaint Details
Complaint 97176-C and facility reported incident 97214-I were investigated and not substantiated.
Inspection Report
Original Licensing
Census: 6
Deficiencies: 4
Sep 9, 2020
Visit Reason
The inspection was conducted as the facility's initial health survey and included a COVID-19 Focused Infection Control Survey.
Findings
The facility was found to be out of compliance with several federal regulations including accuracy of assessments, ADL care for dependent residents, food safety and storage, infection prevention and control, and employee screening. Deficiencies were identified related to incomplete resident assessments, inadequate oral care, unsafe food storage and handling, and failure to properly screen employees for COVID-19.
Deficiencies (4)
| Description |
|---|
| Failure to accurately complete resident assessments for two residents, including incorrect BIMS scores and missing documentation. |
| Failure to ensure staff provided oral care/personal hygiene for one resident. |
| Failure to procure, store, prepare, and serve food in accordance with professional standards for food service safety, including multiple instances of undated, uncovered, or expired food items. |
| Failure to establish and maintain an infection prevention and control program, including inadequate employee screening and failure to follow isolation and hand hygiene procedures. |
Report Facts
Census: 6
Dates of MDS assessments: 3
Number of undated or expired food items observed: 20
Number of times employee screening failed to be documented: 66
Number of visitors missing temperature check: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Observed providing inadequate oral care and improper food handling; interviewed regarding screening and care procedures. |
| Care Center Clinical Administrator | Interviewed regarding MDS completion, staff expectations for oral care, and employee screening procedures. |
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