Prairie Heights Memory Care

Survey completed June 13, 2023: 10 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. This had the potential to affect all 31 residents in the Assisted Living with Dementia Care facility. [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and”

• Tag 510: 144G.41 Subd. 3 Infection control program Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. The deficient practice had the potential to affect all residents, employees, and visitors. [...]”

  Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

• Tag 650: 144G.42 Subd. 8 Employee records Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure current employee records were maintained to include all required content for one of two employees (unlicensed personnel (ULP)-B).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure current employee records were maintained to include all required content for one of two employees (unlicensed personnel (ULP)-B). [...]”

  Rule cited: “(a) The facility must maintain current records of each paid employee, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

• Tag 660: 144G.42 Subd. 9 Tuberculosis prevention and control Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included completion of a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test for two of two employees (director of nursing (DON)-A, unlicensed personnel (ULP)-B).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included completion of a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test for two of two employees (director of nursing (DON)-A, unlicensed personnel (ULP)-B). [...]”

  Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

• Tag 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to maintain the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents. This deficient condition had the potential to affect all staff, residents, and visitors. [...]”

  Rule cited: “(4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance [...]”

From MDH’s letter: the letter says the facility is in substantial compliance; no immediate fines.

Allegation, as written: “The facility neglected the resident when they failed to provide supervision and safety checks during the night. Staff found the resident lying face down on the floor during morning shift change. The resident had been on the floor for an undetermined amount of time. It was reported the resident was not checked on during the overnight shift.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Although staff failed to document they performed safety checks during the night she fell, the resident's progress note indicated unlicensed personnel (ULP) #1 said he checked on the resident around 5:40 a.m., and numerous staff stated safety checks were automatically performed for all residents.”

Action taken by facility: “The facility immediately called 911 when they found the resident and immediately filed a MAARC report.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed November 3, 2022: 3 correction orders

• Tag 510: 144G.41 Subd. 3 Infection control program Level 2, widespread scope, scope/level letter F
  Details

  Summary: MDH found the facility failed to establish and maintain an effective infection control program that complied with accepted health care, medical and nursing standards per the Centers for Disease Control (CDC) guidelines.

  MDH’s finding, as written: “Based on observations, interview and record review, the facility failed to establish and maintain an effective infection control program that complied with accepted health care, medical and nursing standards per the Centers for Disease Control (CDC) guidelines. This had the potential to affect all 28 residents who resided in the facility. [...]”

  Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

• Tag 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 3, widespread scope, scope/level letter I
  Details

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) routinely assessed residents after falls for three of four residents (R2, R3, R4) with records reviewed. As a result, R2, R3, R4 were not assessed for causal fall factors and implement new fall interventions to prevent reoccurrences. [...]”

  Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

• Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 2, widespread scope, scope/level letter F
  Details

  Summary: MDH found the licensee failed to ensure three of four residents (R2, R3, R4) with records reviewed, received all scheduled services as indicated in their records.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure three of four residents (R2, R3, R4) with records reviewed, received all scheduled services as indicated in their records. In addition, R2, R3, R4's service plans were not updated to include new fall preventions after numerous falls with injuries. [...]”

  Rule cited: “(a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. [...]”

Allegation, as written: “The alleged perpetrators (AP #1, AP #2, and AP #3), facility staff members, abused the resident while restraining the resident during administering of medications.”

“The Minnesota Department of Health determined abuse was not substantiated.”

Summary: MDH looked into an allegation and found: abuse not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was not substantiated. Although the actions of AP #1 and AP #3 were inappropriate the facility staff were attempting to administer the resident's pain medication. The incident did not meet the definition of abuse.”

Action taken by facility: “The facility conducted an internal investigation. AP #1, AP #2, and AP #3 are no longer employed at the facility. Following the incident, interventions were put in place for when the resident would refuse medications and training on abuse, neglect, and resident approach was completed for all the staff.”

Action taken by MDH: “No further action taken at this time.”

Survey completed June 2, 2026: no correction orders issued.

Allegation, as written: “The facility neglected the resident when the resident fell several times in about one week. The resident sustained broken ribs and vertebrae.”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. The facility sent the resident to the hospital for evaluation after the first fall when they suspected injury, and again when the resident's agitation persisted for about a week. Facility staff administered as needed medications and communicated with the family and provider.”

Action taken by facility: “The facility completed an internal investigation. The nurse assessed the resident after the falls. The facility continued to provide cares as the resident was willing and administer medications. The facility staff sent the resident to the hospital twice.”

Action taken by MDH: “No further action taken at this time.”

Survey completed January 6, 2025: no correction orders issued.

Allegation, as written: “The facility neglected the resident when the facility failed to provide supervision, the resident exited the building, fell, and fractured her wrist.”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. Although the resident did exit through a secured exit and fell, staff responded immediately and according to facility protocol.”

Action taken by facility: “No action required.”

Action taken by MDH: “No further action taken at this time.”

Survey completed August 19, 2024: no correction orders issued.