Prairie View Healthcare: Safety Hazard Violations - SD
CNA E told inspectors she came up behind the resident's wheelchair on October 22 at 6:30 p.m. and began pushing without asking. The resident was self-propelling down the hallway when the nursing assistant decided she "was struggling" and needed help.
When they turned the corner, the resident told her to stop.
The nursing assistant justified her actions by saying "the resident's care plan looked like she needed help." But inspectors found the facility had failed to follow proper wheelchair safety protocols that require staff to check care plans before assisting and explain procedures to residents.
The incident violated federal requirements for resident dignity and self-determination. Residents who can operate their own wheelchairs have the right to do so without unwanted assistance from staff.
Prairie View's administrator acknowledged the violation during interviews on November 5. She had implemented weekly wheelchair pedal audits three to five times per week to verify residents being transported in wheelchairs had footrests securely attached and used them correctly.
The facility scrambled to address broader wheelchair safety issues after the complaint. Staff received mandatory wheelchair safety education on October 23 through an online platform called Care Feed. All employees who work at the facility attended the training and signed forms confirming they received the education.
CNA F, who attended the training, told inspectors the facility purchased bags to be placed on residents' wheelchairs where pedals could be stored when not being used. She said residents "really like them" and the bags helped staff keep track of wheelchair pedals, especially for residents who self-propel.
The registered nurse and minimum data set coordinator revealed wheelchair audits would continue three to five times per week through November 26. Results would be brought to the facility's quality assurance and performance improvement committee, which meets monthly on the last Wednesday.
RN C, the staff development coordinator, developed an audit form to document observations of residents' wheelchair pedals and verify they were being used appropriately. She confirmed large bags had been purchased for all residents to place on the back of their wheelchairs for foot pedal storage.
The facility works with Nu Motion, a wheelchair company whose employee came to measure one resident for a custom manual wheelchair, according to the physical therapy assistant.
Prairie View implemented new guidelines following the violation. The protocols require staff to check care plans before assisting residents and explain procedures while asking about resident preferences. Staff must respect privacy and rights at all times and ensure leg rests are out of the way before transfers.
For wheelchair pushing, the guidelines emphasize that "communication is key" and staff must ensure users are comfortable and secure. Staff should be aware of users' needs and preferences and adjust wheelchairs accordingly.
But the damage was already done. The October 22 incident demonstrated how quickly staff assumptions can override resident autonomy. The nursing assistant's belief that the resident needed help superseded the resident's actual ability to navigate independently.
The administrator's weekly audits and mandatory training sessions represent the facility's attempt to prevent similar violations. Whether the corrective measures address the underlying issue of staff respecting resident choices remains to be seen.
Federal inspectors determined the facility achieved substantial compliance by November 5, classifying the wheelchair safety violation as past noncompliance. The investigation found minimal harm to few residents.
The resident who was pushed without permission continues living at Prairie View Healthcare Center, now equipped with a storage bag for wheelchair pedals and the knowledge that staff received additional training on respecting resident dignity.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prairie View Healthcare Center from 2025-11-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PRAIRIE VIEW HEALTHCARE CENTER in WOONSOCKET, SD was cited for violations during a health inspection on November 5, 2025.
CNA E told inspectors she came up behind the resident's wheelchair on October 22 at 6:30 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.