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 Gate during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of bruising reported to staff and family concerns about rough handling by an overnight CNA. Although the LPN communicated these concerns to the charge nurse, no formal report was made to the state agency, and the incident was not investigated as required by facility policy. The DON and administrator were unaware of the allegations, resulting in a failure to report suspected abuse.
A resident with cognitive impairment and a history of bruising reported to staff, along with her family, concerns about rough handling by an overnight staff member during care. Although an LPN communicated these concerns to the charge nurse, there was no evidence that a formal assessment or investigation was conducted, nor was the incident reported to the state agency, contrary to facility policy.
A resident with a history of multiple bruises and a recent hip hematoma reported to staff and family that an overnight CNA was rough during care, leading to concerns about new bruising. Although the LPN reported the complaint to the charge nurse, no assessment or occurrence report was completed as required by facility policy, and documentation of skin alterations was incomplete.
A CNA did not follow proper hand hygiene protocols while providing catheter care to a resident with severe cognitive impairment and an indwelling catheter on Enhanced Barrier Precautions. Hand hygiene was not performed between glove changes or after glove removal, contrary to facility policy and expectations, resulting in a breach of infection prevention practices.
A resident with severe cognitive impairment and multiple diagnoses was injured after a CNA transferred her in a wheelchair without placing her feet on the foot pedals, causing her to fall and sustain a contusion and abrasion. The care plan required a tilt-in-space wheelchair and proper transfer assistance, but these procedures were not followed, as confirmed by video review and staff interviews.
A resident with impaired mobility and a recent arm injury was handled roughly by an agency CNA during nighttime personal care, resulting in pain and distress. The resident reported being unable to turn herself in bed and that the CNA pulled on her injured arm despite her protests. Multiple staff and the resident's family confirmed the resident's account, noting her upset state and pain following the incident. The facility's policy on resident rights was not followed, as the resident was not treated with dignity and respect during care.
A resident with severe cognitive impairment and an elopement risk exited through alarmed double doors after a staff member, upon hearing the alarm, assumed the individual was someone else and turned off the alarm without verifying the resident's identity or notifying nursing staff, contrary to facility protocol. The resident was later found and returned without injury.
The facility did not post the daily nursing census in a prominent area accessible to residents and visitors. The census was found at the nurse's station without the required posting of nursing and CNA hours. A staff member posted the schedule by the front door, unaware it needed to be visible to residents on the second floor, contrary to the facility's policy.
The facility failed to store food according to safe practices, as observed during a kitchen tour. The DM found several undated and open containers in the refrigerator and dry storage, including fruit cups, soup, raw broccoli, cilantro, potato chips, and cherries. A container of raw chicken was improperly stored above other fresh foods. The DM acknowledged that staff were expected to date packages upon opening, per the facility's 'Safe Food Storage' policy.
A facility failed to provide dignified care and respect resident rights, as evidenced by a CNA's rough handling of residents during transfers and a resident being coerced into a shower despite refusal. Several residents reported feeling anxious and undignified due to the CNA's actions, which included not following care plans and rushing through care. Documentation and communication issues also contributed to the failure to respect a resident's right to refuse care.
A facility failed to provide sufficient nursing staff, resulting in delayed call light responses for several residents. One resident, with no cognitive impairment, reported staff shortages during the evening shift, leading to response times exceeding 15 minutes. Another resident, with moderate cognitive impairment, experienced delays up to 24 minutes, affecting her ability to prevent incontinence. A third resident, dependent on staff for transfers, faced response times up to 80 minutes, while a fourth resident, at risk for falls, reported delays over an hour. The facility's policy required prompt call light responses, but recent times exceeded expectations.
A resident reported that her bed linen had not been changed for two weeks, which was confirmed by observations. The facility's policy requires weekly linen changes, but a CNA admitted to not changing the bedding on the scheduled day and communicated this to the next shift. However, the next shift did not change the bedding, leading to the deficiency.
A facility failed to accurately assess a resident's status in the MDS, incorrectly coding insulin injections despite no orders for insulin. The resident's MAR showed no insulin orders, and the DON confirmed the coding error, contrary to the facility's RAI policy requiring accurate assessments.
A resident with moderate cognitive impairment requiring oxygen was found with undated oxygen tubing and nebulizer mask. Staff provided conflicting information about the schedule for changing respiratory supplies, with no consistent practice or documentation. The DON confirmed the expectation for weekly changes, which was not followed.
A resident with moderate cognitive deficit and multiple health conditions was transferred by a CNA without the required assistance or use of a gait belt, contrary to the care plan. The CNA had a history of not following care plans and being rough with residents, leading to multiple warnings and a suspension. Other staff and residents expressed concerns about his handling, and the facility's policy on using gait belts was not adhered to.
A resident in an LTC facility experienced a significant medication error when staff failed to follow a cardiologist's order for Bumetanide, resulting in the resident receiving an incorrect dosage for an extended period. This error contributed to the resident developing an acute kidney injury, as the facility did not properly process and clarify the medication orders.
A facility failed to ensure an LPN maintained the appropriate licensure to practice in Iowa. The LPN's license changed from a multistate to a single state valid only in Nebraska, which was not communicated to the facility. The Human Resources Manager, who took over in 2023, did not verify the license since 2021, leading to the oversight. The facility's system failed to detect the change during the 2023 renewal process.
A resident with multiple health conditions received incorrect dosages of Bumetanide due to the facility's failure to clarify and accurately transcribe physician orders. The resident was supposed to receive 2 mg once daily after an initial period of 2 mg twice daily, but continued to receive higher doses due to transcription errors and lack of clarification by the staff.
Failure to Report Suspected Abuse Following Resident Allegations
Penalty
Summary
The facility failed to report an incident of possible physical abuse involving one resident, as required by policy and regulation. The resident in question had a history of cognitive impairment, with documented changes in her Brief Interview for Mental Status (BIMS) scores and a diagnosis of dementia. Upon admission, the resident had significant bruising on her legs and hips, reportedly from a fall at home, and continued to have bruising during her stay. The resident and her daughter both expressed concerns to staff about rough treatment by a female staff member during overnight shifts, specifically mentioning that the resident felt the staff was rough when turning her. Staff interviews revealed that the concerns about rough handling were communicated to nursing staff, including an LPN and charge nurses. The LPN reported the resident's statements about rough treatment to the charge nurse and completed an assessment, but it was unclear if this was documented in the resident's record. The charge nurses and other staff interviewed stated that they did not recall receiving reports of rough treatment or abuse regarding this resident, and no formal report was made to the state agency. The facility's policies required that any suspected abuse be reported immediately to supervisors and the appropriate authorities, but this process was not followed in this case. Despite the facility's established policies for occurrence reporting and abuse prevention, the incident was not reported to the state agency, and there was no evidence of a formal investigation or protective measures being initiated. The administrator and DON confirmed that they were unaware of any reports of possible abuse or rough treatment involving this resident, and therefore no report was made to the state agency. This failure to report and investigate the alleged abuse constituted a deficiency in the facility's compliance with regulatory requirements for protecting residents from abuse.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving a resident who had a history of cognitive impairment and multiple bruises upon admission. The resident, who had a diagnosis of unspecified dementia and a fluctuating BIMS score indicating periods of moderate cognitive impairment, was noted to have significant bruising on her legs and hips, reportedly from a fall at home prior to admission. During her stay, the resident and her daughter expressed concerns to staff about rough treatment by an unidentified female staff member during overnight shifts, particularly when the resident was being turned or cleaned due to C-diff-related loose stools. Staff interviews revealed that the concerns about rough handling were communicated to at least one LPN, who reported the information to the charge nurse. However, there was no documentation or evidence that a formal assessment or investigation was initiated in response to these allegations. The charge nurses and other staff interviewed either did not recall receiving such reports or stated that no further action was taken. The facility's policies required that any suspected abuse be reported, investigated, and, if necessary, reported to the state agency, but this process was not followed in this case. Despite the facility's policies and the statements from staff and administration outlining the required procedures for handling abuse allegations, there was no indication that the incident involving the resident's report of rough treatment was investigated or reported to the state agency. The lack of documentation and follow-up on the reported concerns constituted a failure to respond appropriately to an alleged violation, as required by facility policy and regulatory standards.
Failure to Assess and Document After Resident Reported Rough Care and Bruising
Penalty
Summary
The facility failed to complete an assessment when a resident reported bruising related to a staff member being rough during care. The resident, who had a history of a fall at home resulting in a right hip hematoma and multiple bruises, was admitted to the facility with documented bruising on her legs and hips. Despite weekly body audits, the documentation did not include measurements of skin alterations, and there was inconsistency in the recorded location of the hematoma. The resident and her daughter reported concerns to nursing staff about rough handling by an overnight staff member, but the staff could not identify the specific individual involved. Staff interviews revealed that the LPN who received the complaint reported it to the charge nurse but did not document an assessment or complete an occurrence report as required by facility policy. The LPN stated that it was difficult to determine if new bruising was present due to the pre-existing bruises from the resident's fall at home. The Director of Nursing and the Administrator both acknowledged that an assessment should have been completed in response to the report of rough care, but no such assessment was found in the resident's records. Facility policy required that any employee discovering or observing an event report it to a supervisor so that immediate and necessary action could be taken, including completion of an occurrence report. However, the lack of documentation and assessment following the resident's report of rough handling constituted a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Adhere to Hand Hygiene Protocols During Catheter Care
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to follow appropriate infection prevention and control practices while providing catheter care to a resident with severe cognitive impairment and an indwelling catheter, who was also on Enhanced Barrier Precautions (EBP). During the observed care, the CNA performed hand hygiene and donned gloves and a gown, but did not perform hand hygiene between glove changes or after removing gloves at several points in the procedure. Specifically, after cleansing the catheter tubing and removing gloves, the CNA did not perform hand hygiene before donning new gloves. Additionally, after emptying the catheter bag and removing gloves, hand hygiene was again omitted before proceeding with the next steps. The Director of Nursing (DON) confirmed that the facility's expectation was for staff to perform hand hygiene between glove changes and when moving from one contaminated area to another, in accordance with the facility's infection control policy. The policy also required hand hygiene before and after resident contact, after contact with contaminated surfaces, before donning PPE, and after removing PPE. The observed failure to adhere to these procedures constituted a breach of the facility's infection prevention and control program.
Failure to Ensure Safe Wheelchair Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, vascular dementia, depression, rheumatoid arthritis, and cancer was not properly protected from accident hazards during a wheelchair transfer. The resident required partial to moderate assistance for transfers and used a wheelchair for mobility. During an incident after a meal, a CNA assisted the resident by pulling the wheelchair away from the dining table and began pushing her forward without ensuring her feet were placed on the foot pedals. As a result, the resident's feet were under the foot pedals, and she fell out of the wheelchair, sustaining a contusion to the left forehead and an abrasion with bruising. The care plan for the resident indicated the use of a tilt-in-space wheelchair for mobility due to limited physical mobility and impaired self-care abilities. Despite this, the staff member failed to follow proper transfer procedures, as confirmed by video footage and staff interviews. The DON confirmed that the expectation was for staff to ensure residents' feet are on the foot pedals during transfers, which was not done in this case, directly leading to the resident's fall and injury.
Failure to Provide Dignified and Respectful Care During Personal Assistance
Penalty
Summary
A resident with no cognitive impairment and a history of polyosteoarthritis and thyroid disease required assistance with activities of daily living (ADLs), including bed mobility and toileting, due to physical debility and impaired mobility. The resident's care plan specified the need for one staff member to assist with a gait belt and walker for ambulation and transfers, and to provide assistance as needed for bed mobility. On one occasion, the resident experienced right shoulder pain after being assisted by a staff member during the night. According to interviews and documentation, the resident reported that a staff member on the overnight shift entered her room multiple times, woke her, and instructed her to roll over while she was lying flat in bed. The resident stated she was unable to turn without something to grab onto, but the staff member insisted and ultimately pulled on her right arm to turn her, causing pain in an arm that had recently been injured in a fall. The resident described the staff member's attitude as gruff and lacking compassion, and expressed concern for other residents who might not be able to speak up about similar treatment. The resident's daughter and other staff corroborated the resident's account, noting that the resident was upset and in pain following the incident. Further interviews with staff revealed that the staff member in question, an agency CNA, denied pulling on the resident's arm but acknowledged the bed was flat and that the resident had no side rails to assist with turning. Other staff who cared for the resident after the incident observed that the resident was upset, felt trapped, and complained of being handled roughly. The resident, who was not known to complain about staff, specifically described the care as rough and painful, prompting staff to report the incident. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and respect, which was not upheld in this instance.
Failure to Properly Respond to Door Alarm Allows Resident Exit
Penalty
Summary
A resident with severe cognitive impairment and a history of elopement risk exited the care center through alarmed double doors without proper staff intervention. The resident required partial to moderate assistance for mobility and transfers, and his care plan included specific interventions such as door security systems, closed double doors, and frequent checks. On the day of the incident, the resident left the unit through the double doors, which triggered the alarm. A staff member, upon hearing the alarm, looked down the hall, saw a male resident heading toward the Bistro, and mistakenly assumed it was another resident who would be signed out by independent living. The staff member turned off the alarm without verifying the identity of the individual or notifying nursing staff as required by protocol. The resident was later found outside the care center double doors, attempting to locate his room, and was returned to his room without injury. The facility's policy required staff to respond to door alarms by identifying the cause and notifying the charge nurse if the cause was unknown. The staff member involved admitted to not being certain of the resident's identity and acknowledged that he should have checked on the resident and been more proactive. The administrator confirmed that the staff member did not follow protocol by failing to verify who set off the alarm.
Failure to Post Daily Nursing Census in Accessible Area
Penalty
Summary
The facility failed to post the daily nursing census in a prominent area accessible to visitors and residents, as required by their policy. During an observation on August 13, 2024, it was noted that the daily nursing census was posted at the nurse's station, but there was no posting of the number of nursing and certified nurse aide hours. On the following day, a staff member responsible for scheduling stated that she had printed the daily schedule with hours and posted it by the front door on the first floor. However, she was unaware that it needed to be posted where the residents, who were housed on the second floor, could see it. The facility's policy, modified in October 2022, specified that nursing staff data should be posted in a designated public area by staffing personnel, in a place readily accessible to residents and visitors.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure that food was stored according to safe practices, as observed during an initial tour of the kitchen. The Dietary Manager (DM) provided the tour, during which several undated and open containers were found in both the walk-in refrigerator and dry storage area. Specifically, the refrigerator contained a tray of individual cups of fruit, a container of soup, a bag of raw broccoli, and a bag of cilantro, all open and undated. Additionally, a container of raw chicken was improperly stored on the top shelf above other fresh foods. In the dry storage area, there were open and undated bags of potato chips, dehydrated cherries, and a container of cherries in juice. The DM acknowledged that staff were expected to date packages as soon as they were opened, in accordance with the facility's policy titled 'Safe Food Storage,' which was updated in May 2019. This policy mandates that staff label, date, and properly cover all food items upon opening. Furthermore, the policy specifies the correct order for storing food products in a refrigerator, from top to bottom: prepared ready-to-eat items, fish and seafood, whole cuts of raw beef, whole cuts of raw pork, ground or processed meats, and raw poultry.
Failure to Provide Dignified Care and Respect Resident Rights
Penalty
Summary
The facility failed to provide care in a dignified manner for several residents, as evidenced by the actions of Staff A, a Certified Nurse Aide (CNA). Resident #21, who had a moderate cognitive deficit and required assistance with transfers, reported being handled roughly by Staff A. The resident and her family member described incidents where Staff A did not use a gait belt or follow the care plan, resulting in painful and undignified transfers. Staff A had a history of disciplinary actions for similar behavior, including rushing through care and not following safe transfer techniques. Resident #11, also with a moderate cognitive deficit, experienced undignified treatment when Staff A grabbed her by the shirt and pushed her back to her room after finding her in another resident's room. This incident left the resident feeling nervous and apprehensive about Staff A's presence. Similarly, Resident #6, who was dependent on staff for transfers, reported that Staff A was in a hurry and did not listen to her requests to slow down, resulting in a fall during a transfer from the toilet. Additionally, the facility failed to respect Resident #17's right to refuse care. Despite expressing that she had already showered the previous day, Resident #17 was coerced into taking another shower by staff, who did not allow her to refuse. This incident left the resident feeling upset and undignified, as she felt she had no choice in the matter. The facility's documentation and communication issues contributed to this situation, as staff were not aware of the resident's previous shower and did not properly document or communicate the care provided.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights, compromising resident safety. This deficiency was identified through electronic health records, document reviews, and interviews with residents and staff. Four residents were specifically noted to have experienced delays in call light responses, with times exceeding the facility's expectation of less than 15 minutes. The facility had a census of 32 residents at the time of the survey. Resident #9, who had no cognitive impairment, reported that the facility was often short-staffed during the evening shift, resulting in call light response times occasionally exceeding 15 minutes. Documentation showed instances where the call light was not answered for up to 34 minutes. Resident #12, with moderate cognitive impairment, also experienced delays, with call light response times reaching up to 24 minutes. She reported having to wait longer than 15 minutes to prevent incontinence, leading her to take herself to the bathroom. Resident #6, with a moderate cognitive deficit and total dependence on staff for toileting and transfers, experienced significant delays, with response times reaching up to 80 minutes. Her family reported that she would sometimes call them for assistance when her call light was out of reach. Resident #8, who was totally dependent on staff for transfers and at risk for falls, reported call light response times exceeding an hour, with one instance taking over two hours. The facility's policy required prompt response to call lights, but the Director of Nursing acknowledged that recent response times had exceeded expectations.
Failure to Change Resident's Bed Linen
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for Resident #9 by not changing the bed linen for two weeks. Resident #9, who has no cognitive impairment as indicated by a BIMS score of 15, reported on August 12, 2024, that her bedding had not been changed in two weeks. Observations on August 13, 2024, confirmed that the same bedding was still on Resident #9's bed. The facility's policy, as stated by the Director of Nursing (DON), requires bed linens to be changed weekly, with a specific schedule posted in the nursing office. Staff G, a CNA, admitted to not changing the bedding on the scheduled day, Monday, and communicated this to the next shift, asking them to change the sheets if they had time. However, Staff H, another CNA, stated that she did not change any bedding on her shift and was not informed by the morning shift that any bedding needed to be changed. This lack of communication and adherence to the facility's bed linen schedule resulted in the deficiency observed by the surveyors.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to complete an accurate assessment for a resident during the observation period of the Minimum Data Set (MDS). The MDS assessment for the resident documented a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. However, the resident stated she did not take insulin, and a review of her Medication Administration Record (MAR) since admission revealed no physician orders for insulin. Despite this, the MDS was incorrectly coded to reflect insulin injections. The Director of Nursing (DON) acknowledged that the MDS should have been coded as an injection, not insulin, indicating an error in the assessment process. The facility's policy on the Resident Assessment Instrument (RAI) Process emphasizes the need for accurate assessments supported by clinical records, which was not adhered to in this case.
Inconsistent Respiratory Care for Resident
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for a resident requiring the use of oxygen. Resident #29, who has moderate cognitive impairment, was observed with undated oxygen tubing and a nebulizer mask. The resident reported not having seen the tubing changed during her stay. Staff interviews revealed inconsistencies and a lack of clarity regarding the schedule and responsibility for changing oxygen supplies. Staff members provided conflicting information about when and how often the oxygen tubing and nebulizer equipment were changed, with some stating it was done weekly, while others were unsure or only changed the equipment when visibly soiled. Further investigation showed that there was no consistent practice or documentation for changing the oxygen tubing. Staff members were unaware of any checklist or specific schedule for changing the equipment, and the tubing was not dated as expected by the facility's policy. The Director of Nursing (DON) confirmed that the facility's expectation was for the oxygen tubing to be changed weekly and dated, but this was not consistently followed or documented in the treatment administration record.
Failure to Follow Safe Transfer Techniques
Penalty
Summary
The facility failed to ensure safe transferring techniques for a resident, leading to a deficiency. Resident #21, who had a moderate cognitive deficit and required substantial assistance with transfers due to conditions such as cancer, anemia, heart failure, and hemiplegia, was transferred by Staff A, a CNA, without the required assistance of a second person or the use of a gait belt. The resident and her family member reported that Staff A was rough during transfers, lifting her under the arms and dropping her into a chair, which caused her pain. The care plan specified that the resident required two staff members for transfers using a sit-to-stand mechanical lift, but Staff A did not adhere to these guidelines. Staff A had a history of not following care plans and being rough with residents, as documented in his personnel file. He had received multiple warnings and a suspension for similar behavior, yet continued to disregard safe transfer techniques. Other staff members and residents expressed concerns about his rough handling and lack of compassion, with several residents requesting not to be cared for by him. The facility's policy required the use of gait belts for all transfers of weight-bearing residents needing assistance, which Staff A failed to follow, contributing to the deficiency.
Medication Error Leads to Acute Kidney Injury
Penalty
Summary
The facility failed to follow a cardiologist's order for a resident's medication, resulting in a significant medication error. The cardiologist had ordered Bumetanide 2 mg to be taken twice daily for three days, followed by a once-daily dosage. However, the facility did not initiate the once-daily order, leaving the resident without Bumetanide from March 10 to March 15. Subsequently, the resident received 2 mg twice daily instead of the prescribed 2 mg once daily, and later received 5 mg daily when only 3 mg was ordered. The resident, who had a BIMS score of 15 indicating no cognitive impairment, had multiple diagnoses including heart failure and hypertension. The care plan directed staff to administer medications as ordered and monitor for side effects. Despite this, the resident experienced a significant medication error that went unnoticed for an extended period, leading to an acute kidney injury. The error was discovered when the resident was sent to the hospital due to abnormal lab results. The facility's documentation revealed discrepancies in the medication orders, with different pages showing conflicting instructions. Staff interviews indicated a lack of clarity and communication regarding the orders, with some staff assuming others had verified the orders. The failure to properly process and clarify the medication orders led to the resident receiving an incorrect dosage of Bumetanide, contributing to the resident's acute kidney injury.
Removal Plan
- the facility educated all nurses on processing, initiating, reconciling, and clarification of orders
- the clinical coordinator/designee will audit orders received to ensure staff initiate and clarify orders when new orders are received
- results of these audits will be reported to the QAPI committee for review and modifications as needed
Failure to Verify LPN Licensure
Penalty
Summary
The facility failed to ensure that one of its employed nurses, specifically an LPN, maintained the appropriate licensure to practice in the state of Iowa. The LPN, identified as Staff A, was initially hired with a multistate license that allowed practice in Iowa, but later transitioned to a single state license valid only in Nebraska. This change in licensure status was not communicated to the facility, and the discrepancy was discovered during a review of employee files. The Human Resources Manager, who assumed her role in May 2023, acknowledged the oversight and confirmed that the facility's system for verifying licenses had not been triggered to catch this change. The facility's internal processes, including the employee handbook and position descriptions, clearly state the requirement for staff to maintain current licensure as a condition of employment. Despite these guidelines, the lapse in monitoring and verification allowed Staff A to continue employment without the necessary Iowa licensure. The Human Resources Manager admitted to not running a verification report for Staff A since 2021, which contributed to the oversight. The facility's administrator also confirmed that the change in licensure status was not detected during the renewal process in 2023, indicating a failure in the facility's system to ensure compliance with state licensure requirements.
Failure to Clarify and Transcribe Medication Orders
Penalty
Summary
The facility failed to clarify and accurately transcribe physician orders for a resident, leading to incorrect administration of the medication Bumetanide. The resident, who had a BIMS score of 15 indicating no cognitive impairment, was diagnosed with multiple conditions including heart failure and hypertension. The care plan required staff to administer medications as ordered and monitor the resident's weight and lab work. However, discrepancies in the medication orders were not clarified, resulting in the resident receiving incorrect dosages. The resident was initially ordered to receive Bumetanide 2 mg twice daily for three days, then once daily. However, the facility did not initiate the once-daily order after the three-day period, leading to a gap in medication administration from March 10 to March 15. During this time, the resident received 4 mg daily instead of the prescribed 2 mg. Further discrepancies occurred when the resident was ordered to receive 3 mg daily starting March 27, but continued to receive 5 mg daily. Interviews with staff revealed that the orders were not properly reviewed and clarified. The Director of Nursing acknowledged that the order was not entered correctly and should have been clarified. Staff members admitted to missing parts of the order and failing to ensure that the orders were accurately transcribed and implemented. The facility's policies on order processing and medication administration were not followed, contributing to the deficiency.
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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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Nursing homes near Council Bluffs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie Gate | 0.6 mi | — | 0 | 0 |
| Prairie Gate | 0.6 mi | — | 0 | 0 |
| Bethany Lutheran Home | 0.8 mi | ★★★★★ | 13 | 1 |
| North Crest Living Center | 1.6 mi | ★★★★★ | 3 | 0 |
| Chapters Living Of Council Bluffs | 1.6 mi | ★★★★★ | 59 | 1 |
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