Prairie Gate

In the surveyor’s words

From the most serious findings on record at Prairie Gate, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Jun 5, 2024

  Based on clinical record review, Pharmacy Drug Book review, clinical staff interview, provider interview, staff interviews, and facility policy review the facility failed to follow physician's orders resulting in a significant medication error for 1 of 3 residents (Resident #1) reviewed. On 3/7/24 the Cardiologist ordered Bumetanide 2 mg BID x 3 days then 2 mg once a day. The facility failed to initiate the once a day order. The resident was without her Bumetanide from 3/10/24-3/15/24. On 3/15/24 at 8:00 PM through 5/23/24 the resident received Bumetanide 2 mg BID when it was ordered for her to receive 2 mg once a day. On 3/27/24 the facility initiated an order for Bumex 1 mg at noon, with the 2 mg order in place. […]

• Actual harm, isolatedF686Feb 29, 2024

  Based on observation, staff interviews, provider interview, clinical record review and facility policy review the facility failed to implement interventions to prevent worsening of a pressure sore for 1 of 3 residents reviewed. On 2/21/24 Resident #1 presented with a pressure sore on his heel. Staff failed to obtain and implement physician treatment orders until 2/27/24. The facility reported a census of 29 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• Actual harm, isolatedF684Nov 1, 2022

  Based on clinical record review, observation, staff interview, and facility policy review, the facility failed to assess a resident's wounds for 1 of 4 residents reviewed for wounds (Resident #4). The facility failed to perform follow up skin assessments and interventions on Resident #4's right lower extremity wound after first identifying the skin concern on 10/11/22, which subsequently resulted in deterioration of the wound. The resident's physician ordered antibiotics for the resident on 10/25/22. The facility reported a census of 16 residents. Findings include: The minimum data set (MDS) assessment dated [DATE] revealed Resident #4 had diagnoses of Alzheimer's disease, hemiplegia (paralysis on one side of the body), and an unstageable pressure ulcer to her right ankle. […]

• No harm, potential for more than minimal, patternF550Aug 15, 2024

  Based on observations, resident interviews, staff interviews, facility investigation review, personnel file review and clinical record review the facility failed to ensure care was provided in a dignified manner for 3 of 14 residents (Resident #21, #11, and #6) reviewed for dignity. The facility also failed to ensure residents can exercise their rights by refusing cares for 1 of 3 residents (Resident #17) reviewed for resident rights. The facility reported a census of 32 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #21 had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficit). […]

• No harm, potential for more than minimal, patternF725Aug 15, 2024

  Based on electronic health records (EHR), document review, resident interviews, and staff interviews the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 4 residents reviewed (Resident #6, #8, #9, and #12). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #9 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Review of EHR documented Resident #9 resided in room [ROOM NUMBER]. On 8/12/24 at 11:05 AM Resident #9 stated the facility was short of staff on the evening shift. Resident #9 stated sometimes there was only one person for the whole hall. […]