Prairie Heights Healthcare

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF851Jul 31, 2025

  Based on Payroll Based Journal (PBJ) CASPER (Certification and Survey Provider Enhanced Reporting) reports, interview, and record review, the provider failed to ensure the PBJ data was submitted accurately to the Centers for Medicaid and Medicare Services (CMS) for Federal Fiscal Quarter 2 (January, February, and March 2025). Findings include:1. Interview on 7/29/25 at 4:20 p.m. with administrator A regarding Fiscal Year 2025 Second Quarter (Q2) PBJ data revealed that the data was submitted to the contracted submission company, and there had been an error, but she did not recall what the error was. Follow-up interview on 7/29/25 at 4:59 p.m. with administrator A regarding Fiscal Year 2025 Q2 PBJ data submission confirmed the data submission had not been accepted by CMS due to an error. […]

• No harm, potential for more than minimal, widespreadF812Mar 7, 2024

  Based on observation, interview, and record review, the provider failed to: *Maintain clean and sanitary conditions of appliances and utensils in one of one kitchen: -Convection oven. -Flattop griddle grease trap drawer. -Stovetop backsplash. -Oven doors. -Dishwasher. -Walk-in refrigerator. -Reach-in refrigerator. -Scoop storage in the bulk oats and brown sugar containers. *Maintain the cleanliness of the microwave and sanitary storage under the sink in one of one rehabilitation (rehab) kitchenette. Findings include: 1. Initial kitchen observation on 3/5/24 from 7:45 a.m. to 8:15 a.m. revealed: a. In the convection oven: *Baked-on grease was found inside the doors and along the inner surfaces. *Burnt food particles lined the bottom of the appliance. b. […]

• No harm, potential for more than minimal, patternF658Oct 24, 2024

  Based on the South Dakota Department of Health (SD DOH) complaint report, interview, record review, the provider failed to ensure services provided for four of four sampled residents (1,2,3,4,) did not meet professional standards by: *Director of nursing (DON) (B) who did not follow the rights of medication administration nor the facility policy for insulin administration when administering insulin to resident 1. *DON B who did not document a wound assessment at the time of completion or identify it as a late entry when it was documented in resident 4's medical record. *Two certified medication aides (CMA) (C and D) who did not remain within their unlicensed but certified skill set. Findings include: Surveyor 50915 1. 4. Interview on 10/23/24 at 3:30 p.m. […]

• No harm, potential for more than minimal, patternF657Mar 7, 2024

  Based on record review, interview, and policy review, the provider failed to remove outdated code status information (emergent treatment a resident would or would not receive if the heart or breathing were to stop) for 9 of 62 resident care plans (1, 5, 6, 18, 21, 32, 35, 41, and 56). Findings include: 1. Review of resident care plans, electronic medical records (EMRs) and resident paper charts for residents 1, 5, 6, 18, 21, 35, 41, and 56 revealed: *Each resident had an active Do Not Resuscitate (DNR) code status in the EMR and paper charts, but the care plans included both Full Code and DNR code statuses. *It appeared as though the above resident's code status was Full Code upon admission to the facility and had since changed to DNR. […]

• No harm, potential for more than minimal, isolatedF760Oct 24, 2024

  Based on South Dakota Department of Health (SD DOH) complaint online report, interviews, record review, and policy review, the provider failed to keep one of one resident (1) free from a significant medication error when administered an incorrect dose of insulon by director of nursing (B). Findings include: 1. Review of SD DOH 10/4/24 complaint report revealed: *DON B had a major medication error where she gave the incorrect insulin (large dose) to a resident but it was never reported or counted as a medication error. *The complainant identified the resident in this incident as resident 1. 2. Interview on 10/22/24 at 2:40 p.m. […]