Deficiencies (last 4 years)
Deficiencies (over 4 years)
1.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
61% better than South Dakota average
South Dakota average: 3.3 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 17, 2025
Visit Reason
The inspection was conducted following a facility-reported incident involving a resident fall during transfer by a certified nursing assistant who did not follow the resident's care plan and failed to report the fall.
Complaint Details
The complaint investigation was substantiated. The fall incident involved one sampled resident who fell during transfer by a CNA who did not follow the care plan and failed to report the fall. The facility implemented corrective actions including staff education, competency training, audits, and a QAPI meeting.
Findings
The provider failed to provide adequate supervision and assistance during a resident transfer, resulting in a fall. The incident was not reported timely, no fall assessment was initially completed, and the staff did not follow the resident's care plan requiring mechanical lift and two-person assistance.
Deficiencies (1)
F 0689: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. The facility failed to provide adequate supervision and assistance during a resident transfer, resulting in a fall and failure to report the incident timely.
Report Facts
Date of fall incident: Jun 29, 2025
Date of report to DON: Jun 30, 2025
Date of CNA termination: Jul 1, 2025
Date of QAPI meeting: Jul 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Involved in resident fall incident and terminated following investigation |
| CNA B | Certified Nursing Assistant | Witnessed fall incident and reported to nurse |
| LPN E | Licensed Practical Nurse | Notified Director of Nursing of fall incident and initiated follow-up assessments |
| DON D | Director of Nursing | Oversaw incident review, instructed assessments, and coordinated corrective actions |
| RN F | Registered Nurse | Responded to fall incident and assessed resident |
| Administrator A | Administrator | Reviewed fall sensor footage, suspended CNA, and led corrective action efforts |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident acquiring a skin tear caused by a hazardous bed frame in the nursing home.
Complaint Details
The complaint investigation found that a resident sustained a skin tear from the bed frame. The resident and family declined emergency room evaluation. The bed frame was initially uncovered, but after the incident, a sheepskin cover was placed. The CNA involved in the transfer was a traveler no longer employed at the facility.
Findings
The provider failed to ensure the bed frame was maintained free of hazardous sharp areas, resulting in a resident sustaining a skin tear on her right lower outer ankle. The bed frame had exposed metal bars without protective caps, which were later covered with a sheepskin cover after the injury was reported.
Deficiencies (1)
F 0689: The nursing home failed to ensure a bed frame was free from accident hazards, causing a skin tear to a resident's right lower outer ankle during transfer. The bed frame had exposed metal bars without protective caps, which were not addressed promptly.
Report Facts
Wound measurement: 6
Wound measurement: 3
Wound measurement: 0.5
Wound measurement: 6
Wound measurement: 2.2
Wound measurement: 0.1
Wound measurement: 8
Wound measurement: 3
Wound measurement: 0.5
Number of metal bars on bed frame: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Confirmed communication with maintenance staff and bed frame issue |
| RN C | Registered Nurse | Confirmed placement of sheepskin cover over bed frame |
| RN E | Registered Nurse | Evaluated resident's wound and bed, did not report bed hazard initially |
| LPN F | Licensed Practical Nurse | Provided wound care to resident |
| CNA D | Certified Nursing Assistant | Assisted with wound care dressing removal |
| Director of Nursing B | Director of Nursing | Expected reporting of equipment problems and investigation of bed frame |
| CNA I | Certified Nursing Assistant | Assisted resident during transfer when skin tear occurred; identified as a traveler no longer employed |
| Maintenance Staff H | Maintenance Staff | Notified about bed frame issue by Administrator A |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to evaluate compliance with care planning and safety regulations, including the timeliness of nutritional care plan updates and side rail assessments.
Findings
The provider failed to update 48-hour nutritional care plans for two sampled residents in a timely manner and did not complete quarterly side rail assessments for three residents. These deficiencies were identified through record reviews, interviews, and observations.
Deficiencies (2)
F 0657: The provider failed to ensure the 48-hour nutritional care plans for two of four sampled residents were updated in their comprehensive care plan within the required timeframe.
F 0700: The provider failed to ensure quarterly side rail assessments were completed for three of seven residents using side rails, including lack of assessments and missing physician orders.
Report Facts
Weight loss: 5.8
Side rail audit date: May 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager H | Dietary Manager | Interviewed regarding care plan completion and acknowledged delays in updating comprehensive care plans. |
| Director of Nursing A | Director of Nursing | Interviewed about care plan expectations and side rail assessments; acknowledged deficiencies. |
| Maintenance Director E | Maintenance Director | Interviewed about side rail assessments and audit documentation. |
| Minimum Data Set Coordinator F | Minimum Data Set Coordinator | Interviewed regarding side rail assessments and confirmed lack of assessments. |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 17, 2022
Visit Reason
The inspection was conducted to assess compliance with infection prevention and control protocols, specifically focusing on hand hygiene practices among staff during resident care.
Findings
The provider failed to ensure proper hand hygiene was performed by staff during care activities for several residents, including personal care, wound care, and medication administration via feeding tube. Observations and interviews revealed multiple instances of staff not performing hand hygiene between glove changes and after care tasks, contrary to facility policy.
Deficiencies (1)
F 0880: The provider failed to ensure proper hand hygiene was performed by three of five observed staff while providing care for three residents, including during personal care, wound care, and medication administration via feeding tube.
Report Facts
Residents affected: 3
Staff observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Named in hand hygiene deficiency during personal care for resident 28 |
| RN C | Registered Nurse | Named in hand hygiene deficiency during wound care for resident 20 |
| LPN D | Licensed Practical Nurse | Named in hand hygiene deficiencies during wound care and medication administration via feeding tube |
| DON B | Director of Nursing | Interviewed regarding hand hygiene expectations and observations |
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