Deficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% worse than South Dakota average
South Dakota average: 3.3 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 11, 2025
Visit Reason
The inspection was conducted based on a complaint investigation triggered by a facility reported incident involving a medication error by a contracted licensed practical nurse (LPN) during the preparation and administration of physician-ordered medication via a syringe driver.
Findings
The investigation found that the contracted LPN failed to add the instructed distilled water to the syringe medication, resulting in a medication error. Interviews and policy reviews confirmed the error, and no adverse outcomes were reported by the pharmacy or primary care provider. Training gaps for travel staff were also identified.
Complaint Details
The complaint investigation was substantiated based on the facility reported incident and interviews confirming the medication error by LPN F. The error involved omission of distilled water in the syringe preparation. Pharmacy and primary care provider had no concerns of adverse outcomes.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a contracted licensed practical nurse followed professional standards for medication preparation via syringe driver, resulting in a medication error. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Date of medication error: May 12, 2025
Date of incident report review: May 13, 2025
Date of survey completion: Jun 11, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN F | Contracted Licensed Practical Nurse | Named in medication error finding for failing to add distilled water to syringe medication |
| LPN D | Licensed Practical Nurse | Oncoming nurse who identified medication count discrepancy and interviewed regarding the incident |
| G | Assistant Director of Nursing (ADON) | Interviewed LPN F regarding the medication error |
| B | Director of Nursing (DON) | Confirmed medication error and discussed training expectations |
| C | Staff Development Coordinator | Discussed training provided to staff and expectations for travel staff education |
| LPN E | Licensed Practical Nurse | Worked prior shift and provided shift report to LPN F; discussed syringe driver familiarity and training |
Inspection Report
Routine
Deficiencies: 7
Jan 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, infection control, and other facility operations.
Findings
The facility was found deficient in maintaining a clean and safe environment, ensuring accurate and updated resident care plans, proper infection control practices, appropriate use of feeding assistants, coordination of hospice care, and ensuring functional call light systems in resident bathing areas.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to maintain resident rooms and common areas in a clean manner free from strong odors, sticky floors, and damage to walls and bathroom tiles. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop complete and updated care plans addressing residents' current needs including medications, hospice care, and placement on secure memory units. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents on pureed diets and with complicated feeding problems were assisted by certified nursing assistants rather than paid feeding assistants. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly store personal care products labeled 'Keep Out of Reach of Children' for cognitively impaired residents, making them accessible and posing accident hazards. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to post nurse staffing information in a prominent area accessible to all residents and visitors, including resident census and total nursing hours per shift. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure infection prevention and control practices including proper use of personal protective equipment, hand hygiene, and cleaning protocols for residents on transmission-based precautions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure call light systems were accessible and functional in resident shower/tub rooms and bathrooms. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents participating in Feeding Assistant program: 16
Residents on pureed diet in Feeding Assistant program: 6
Residents with wounds requiring enhanced barrier precautions: 5
Residents with inaccessible call lights: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN L | Licensed Practical Nurse | Named in medication administration and feeding assistance observations. |
| Administrator A | Administrator | Interviewed regarding care plans, hospice services, feeding assistant program, and call light policies. |
| DON B | Director of Nursing | Interviewed regarding care plans, hospice services, feeding assistant program, infection control, and staffing data. |
| Cosmetologist AA | Paid Feeding Assistant | Observed assisting resident 19 with eating. |
| Speech Therapist G | Speech Therapist | Responsible for assessing residents for feeding assistant program eligibility. |
| Staff Development Coordinator H | Staff Development Coordinator | Oversaw paid feeding assistant program. |
| Wound Care Nurse I | Wound Care Nurse | Interviewed regarding infection control and wound care practices. |
| CNA X | Certified Nursing Assistant | Observed and interviewed regarding infection control and resident care. |
| LPN N | Licensed Practical Nurse | Observed performing wound care and interviewed regarding infection control. |
| CNA W | Certified Nursing Assistant | Interviewed regarding infection control and feeding assistance. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 4, 2024
Visit Reason
The inspection was conducted following a facility-reported incident involving an unwitnessed fall of a resident who required hospitalization and subsequently passed away. The investigation focused on the facility's failure to ensure resident safety and adequate supervision to prevent accidents.
Findings
The facility failed to ensure the safety of a resident with severe cognitive impairment who had an unwitnessed fall resulting in serious injuries including a fractured hip and brain hemorrhage, leading to hospitalization and death. The facility lacked fall risk assessments and a Fall Policy prior to the incident but implemented corrective actions including staff education, updated policies, and new procedures for neuro checks and documentation post-fall.
Complaint Details
The visit was complaint-related due to a facility-reported incident of an unwitnessed fall of a resident with severe cognitive impairment. The complaint was substantiated as the resident suffered serious injuries and subsequent death. The facility was found non-compliant for failing to conduct fall risk assessments and lacking a Fall Policy prior to the incident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Blood pressure: 92
Blood pressure: 52
BIMS score: 7
Time: 10.25
Time: 9
Time: 15.25
Inspection Report
Routine
Deficiencies: 5
Apr 4, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights, abuse prevention, oral care, pressure ulcer care, and other regulatory requirements at Jenkin's Living Center.
Findings
The facility was found deficient in maintaining resident dignity and privacy, preventing abuse and neglect, providing consistent oral care, and preventing and treating pressure ulcers. Specific issues included failure to maintain privacy during personal care, neglect leading to injury from mechanical lift sling use, inconsistent oral hygiene, and inadequate pressure ulcer prevention and care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Level of Harm - Actual harm: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to maintain privacy during personal care, including not closing window curtains. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect a resident from injury caused by being left in a mechanical lift sling for an extended period. | Level of Harm - Actual harm |
| Failure to timely report an allegation of neglect to the South Dakota Department of Health. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide consistent and documented oral care to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing. | Level of Harm - Actual harm |
Report Facts
Duration left in mechanical lift sling: 101
Pressure ulcer measurements: 15
Pressure ulcer measurements: 4
Pressure ulcer measurements: 5
Pressure ulcer measurements: 20
BIMS score: 11
BIMS score: 9
BIMS score: 14
BIMS score: 15
Braden Scale score: 8
Braden Scale score: 13
Braden Scale score: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN L | Licensed Practical Nurse | Did not close window curtain before providing perineal care to resident 3. |
| LSW K | Licensed Social Worker | Confirmed privacy standards and resident name usage policies. |
| CNA E | Nurse Aide | Called residents by inappropriate names and failed to ensure call light accessibility. |
| CNA Q | Certified Nursing Assistant | Failed to ensure call light was within reach of resident 3. |
| DON B | Director of Nursing | Provided statements on resident care practices and investigation of neglect allegation. |
| ADM A | Administrator | Reviewed facility camera footage confirming neglect allegation and discussed reporting. |
| RN R | Registered Nurse | Documented wound assessment for resident 1. |
| LPN R | Licensed Practical Nurse | Provided interview regarding pressure ulcer care and resident assistance. |
| WCN D | Wound Care Nurse | Assessed wounds and provided skin care recommendations. |
| LPN H | Licensed Practical Nurse | Provided treatment for resident 13's pressure injuries and managed incontinence care. |
| NA E | Nurse Aide | Assisted residents with morning care but failed to provide oral care and repositioning. |
| CNA N | Certified Nurse Aide | Failed to remove dentures and provide oral care to residents. |
| CNA O | Certified Nurse Aide | Unaware of residents' oral care status and toothbrush availability. |
| LPN P | Licensed Practical Nurse/Nurse Manager | Discussed oral care practices and concerns. |
| Dietary aide G | Dietary Aide | Assisted resident 5 to recliner. |
Inspection Report
Routine
Deficiencies: 7
Oct 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, weight loss monitoring, mechanical lift use, staff competencies, and food safety.
Findings
The facility was found deficient in multiple areas including failure to notify residents of bed hold policies, inaccurate weight assessments and MDS coding, incomplete care plans, unsafe mechanical lift use, inadequate staff orientation for agency personnel, and failure to properly monitor dishwasher sanitization temperatures and disinfect mechanical lifts between uses.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to notify one resident of bed hold notice upon hospital transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate weight assessments and MDS coding for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to update care plans to reflect current resident needs for five residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to assess resident for proper mechanical lift use, sling size, and number of staff required, resulting in a resident fall with head injury. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure orientation for six temporary agency staff prior to working with residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to monitor temperatures for three mechanical dishwashers with incomplete sanitizing logs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to disinfect mechanical lifts and body slings between resident use on two observed occasions. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Weight loss percentage: 8.38
Weight loss percentage: 13.69
Weight loss percentage: 14.91
Weight loss percentage: 11.4
Number of residents affected: 72
Number of agency CNAs: 4
Number of agency LPNs: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Named in multiple interviews regarding facility policies, immediate jeopardy removal plan, and staff orientation |
| Director of Nursing B | Director of Nursing | Named in multiple interviews regarding facility policies, immediate jeopardy removal plan, staff orientation, and mechanical lift assessments |
| Assistant Director of Nursing C | Assistant Director of Nursing | Named in multiple interviews regarding facility policies, immediate jeopardy removal plan, and staff orientation |
| Licensed Practical Nurse K | Licensed Practical Nurse | Interviewed regarding weight loss reporting and disinfecting mechanical lifts |
| Registered Dietitian D | Registered Dietitian | Interviewed regarding weight loss assessments and dishwasher temperature monitoring |
| Certified Nursing Assistant I | Certified Nursing Assistant | Observed transferring resident and not disinfecting mechanical lift equipment |
| Licensed Practical Nurse M | Licensed Practical Nurse | Interviewed regarding weight loss monitoring and resident care |
| Certified Nursing Assistant V | Certified Nursing Assistant | Observed transferring resident and not disinfecting mechanical lift equipment |
Inspection Report
Annual Inspection
Deficiencies: 3
Sep 21, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to food safety, sanitation, and safety assessments of positioning devices in the facility.
Findings
The provider failed to maintain cleanliness of dishwasher ventilation ducts and a food vending machine, and failed to ensure safety assessments were completed for positioning devices for two residents. Observations revealed mold in the vending machine and dust on ventilation ducts, and interviews indicated lack of cleaning schedules and awareness of safety assessment requirements.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Two of three dishwasher ventilation ducts were not maintained in a clean manner. | Level of Harm - Minimal harm or potential for actual harm |
| One food vending machine was not cleaned, with mold and mildew present and broken containers of hard boiled eggs. | Level of Harm - Minimal harm or potential for actual harm |
| Positioning devices for two residents lacked required safety assessments. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Dishwasher ventilation ducts: 3
Residents sampled for positioning devices: 4
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor C | Interviewed regarding dishwasher ventilation ducts and positioning devices | |
| Food Service Supervisor D | Interviewed regarding cleaning of rotating vending machine | |
| Assistant Cook E | Interviewed regarding cleaning of rotating vending machine | |
| Director of Nursing B | Director of Nursing | Interviewed regarding repositioning devices and safety assessments |
| Administrator A | Administrator | Interviewed regarding repositioning devices and safety assessments |
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