Deficiencies (last 3 years)
Deficiencies (over 3 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% better than South Dakota average
South Dakota average: 3.3 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Deficiencies: 1
Jul 31, 2025
Visit Reason
The inspection was conducted to review the accuracy of the Payroll Based Journal (PBJ) data submission to the Centers for Medicaid and Medicare Services (CMS) for Federal Fiscal Quarter 2 (January, February, and March 2025).
Findings
The provider failed to ensure the PBJ data was submitted accurately and the submission was not accepted by CMS due to an error. Interviews with the administrator and accounting clerk revealed lack of awareness and details about the error. The provider's PBJ submission schedule instructions were reviewed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the PBJ data was submitted accurately to CMS for Federal Fiscal Quarter 2. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Federal Fiscal Quarter: 2
PBJ submission due date: 15
Report submission deadline: 45
Interview dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Interviewed regarding Fiscal Year 2025 Q2 PBJ data submission | |
| Accounting Clerk M | Interviewed regarding PBJ data submission and unaware of submission rejection |
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 24, 2024
Visit Reason
The inspection was conducted based on a complaint report from the South Dakota Department of Health regarding medication administration errors, wound assessment documentation issues, and certified medication aides performing duties outside their scope of practice.
Findings
The facility failed to ensure professional standards of quality for four sampled residents, including a medication error where the director of nursing administered the wrong insulin type and dose, failure to document wound assessments properly, and certified medication aides completing assessments outside their certified skill set.
Complaint Details
The complaint was filed anonymously and alleged medication errors, improper wound assessment documentation, and certified medication aides performing unauthorized duties. The complaint was substantiated by interviews and record reviews.
Deficiencies (3)
| Description |
|---|
| Director of nursing administered 55 units of Humalog insulin instead of the ordered 62 units of Lantus insulin to resident 1. |
| Director of nursing did not document a wound assessment at the time of completion or identify it as a late entry for resident 4. |
| Two certified medication aides documented pain and psychotropic medication assessments, which are outside their scope of practice. |
Report Facts
Insulin dosage error: 7
Blood glucose readings: 215
Blood glucose readings: 143
Blood glucose readings: 115
Blood glucose readings: 123
Blood glucose readings: 118
BIMS score: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Named in medication error regarding insulin administration and wound assessment documentation. |
| CMA C | Certified Medication Aide | Documented pain and psychotropic medication assessments outside scope of practice. |
| CMA D | Certified Medication Aide | Documented antipsychotic medication side effects and pain assessment outside scope of practice. |
Inspection Report
Routine
Deficiencies: 3
Mar 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans and food safety standards in the facility.
Findings
The provider failed to remove outdated code status information from resident care plans for 9 residents, potentially causing confusion. Additionally, the kitchen and rehabilitation kitchenette were found to have multiple sanitation and cleanliness issues, including grease buildup, food residue, and improper storage practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to remove outdated code status information from 9 resident care plans, listing both Full Code and Do Not Resuscitate (DNR) statuses. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain clean and sanitary conditions of kitchen appliances and utensils, including convection oven, flattop griddle grease trap drawer, stovetop backsplash, oven doors, dishwasher, walk-in refrigerator, reach-in refrigerator, and scoop storage in bulk containers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain cleanliness of microwave and sanitary storage under the sink in the rehabilitation kitchenette. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents with outdated code status in care plans: 9
Date of code status changes: Specific dates listed for 8 residents ranging from 5/19/23 to 3/1/24.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| F | Registered Nurse (RN) | Interviewed regarding advanced directives process and code status documentation. |
| C | Social Services Designee (SSD) | Interviewed about updating social services section of resident care plans and code status documentation. |
| E | Minimum Data Set (MDS) Coordinator | Interviewed about responsibilities for including code status on care plans. |
| B | Director of Nursing | Interviewed about expectations for updating care plans and resolving outdated information. |
| A | Administrator | Interviewed about approval of care plan documentation practices. |
| D | Food Services Manager (FSM) | Interviewed about kitchen cleanliness and cleaning logs. |
| G | Cook | Interviewed about cleaning schedules for kitchen appliances. |
| I | Dietary Aide (DA) | Interviewed about daily cleaning tasks and cleaning log compliance. |
| H | Dietary Aide (DA) | Interviewed about cleaning tasks and deep cleaning schedules. |
Inspection Report
Annual Inspection
Deficiencies: 0
May 10, 2023
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 8, 2023
Visit Reason
The document is an annual inspection report for Prairie Heights Healthcare conducted to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
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