Prairie View Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 6, 2024

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, and record review, the provider failed to ensure one of one sampled resident (29) was safely transferred out of the facility van while using the hydraulic wheelchair lift, which resulted in the resident sustaining injuries. Findings include: 1. Review of the provider's submitted SD DOH FRI revealed: *On 5/22/24 at around 5:15 p.m., resident 29 was transferred to the facility from the emergency room (ER) via the facility van. *Certified nurse aide (CNA) L instructed the resident several times to keep his arms folded in and on his lap prior to attempting [to] transfer out of the can using the [wheelchair] lift. *CNA L positioned herself on the ramp with the resident. […]

• No harm, potential for more than minimal, widespreadF804Aug 27, 2026

  Based on interview, observation, and policy review, the provider failed to ensure that food was thawed, prepared, kept, and served at a safe temperature in one of one kitchen and that food was palatable, appetizing, and warm by two of two sampled residents (29 and 42), who reported concerns with their food. Findings include: 1. Interview on 8/25/26 at 9:43 a.m. with resident 29 in her room revealed that when she ate in her room, the food was cold most of the time when she received it. She said there were rare days when the food was hot.2. Interview and observation on 8/25/26 at 10:07 a.m. with resident 42 in his room revealed that he did not eat his breakfast. He said the food was terrible. His entire pancake was black on both sides.3. Interview on 8/25/26 at 11:09 a.m. […]

• No harm, potential for more than minimal, widespreadF812Aug 27, 2026

  Based on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure two of two cooks (I and L) maintained safe food temperatures during two of two observed meal services, one of one cook (N) thawed frozen chicken safely before food preparation, and that one of one kitchen was cleaned and maintained by three of three cooks (I, L, and N). Findings include:1. Observations on 8/25/26 from 8:09 a.m. to 8:20 a.m. in the kitchen revealed the floors by the stove, ovens, and dishwasher areas had a large amount of black film over the brown floor tiles, and trash debris including paper towels, straws, food, and wrappers. […]

• No harm, potential for more than minimal, widespreadF880Aug 27, 2026

  Based on observation, interview, and policy review, the facility failed to ensure infection prevention and control practices were followed by one of one registered nurse (RN) (E) and one of one licensed practical nurse (LPN) (F) who did not use enhanced barrier precautions (EBP), including gown and glove use, while changing wound dressings for three of three residents (1, 9, and 25) on EBP and one of one LPN (F) who did not use EBP when administering medications to one of one resident (3), who had a gastrostomy tube (a soft, flexible tube placed through the abdomen directly into the stomach) and a suprapubic catheter (a thin, flexible tube inserted through the lower abdomen into the bladder) and was on EBP. Findings include: 1. Observation on 8/25/26 at 8:52 a.m. […]

• No harm, potential for more than minimal, widespreadF812Jul 24, 2025

  Based on observation, interview, record review, and policy review, the provider failed to:*Follow standard food safety practices to ensure one of one kitchen had been cleaned to maintain a sanitary environment to store, prepare, and serve food to residents related to the cleanliness of the food preparation areas.*Follow acceptable food safety practices by not having ensured that food packages were dated when opened and outdated food items were discarded from inventory in one of one observed kitchen related to food items requiring refrigeration.*Properly temp foods to prevent the spread of cross-contamination by one of one observed cook M during one of one meal services.*Ensure the use of a beard net by one of one food and nutrition service (FANS) manager (F).Findings include:1. […]