Inspection Report Summary
The most recent inspection on July 8, 2025, found deficiencies related to a medication error involving the wrong insulin administration that led to a resident’s hospitalization and a failure to timely report the incident. Earlier inspections showed a pattern of issues including resident care concerns, such as unprofessional conduct by staff and problems with dignified communication, as well as medication management and infection control deficiencies. Complaint investigations substantiated problems with staff behavior and medication errors, while prior annual inspections cited failures in call light accessibility, adherence to physician orders, and infection prevention practices. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history indicates ongoing challenges with medication safety and resident dignity, with no clear trend of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% better than South Dakota average
South Dakota average: 3.3 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 8, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error where a resident was administered the wrong insulin, resulting in hospitalization.
Complaint Details
The complaint investigation was substantiated. The facility failed to report a medication error within 24 hours as required, which involved administering the wrong insulin to a resident, resulting in the resident's transfer to the emergency room and hospitalization.
Findings
The facility failed to report a medication error within the required timeframe after a resident was given 40 units of lispro insulin instead of the prescribed 40 units of glargine insulin by a licensed practical nurse. This error led to the resident's transfer to the emergency department and overnight hospitalization for observation. The insulin that was discontinued was not removed from the medication cart, contributing to the error.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to ensure residents are free from significant medication errors, specifically administering the wrong insulin resulting in hospitalization.
Report Facts
Units of insulin administered: 40
Date of medication error: May 4, 2025
Date report submitted: May 5, 2025
Blood sugar level: 51
Discontinued insulin destruction timeframe: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Administered the wrong insulin to resident 1. |
| Physician G | Medical Director and Primary Physician | On-call physician who was notified of the medication error and ordered resident transfer to ER. |
| Administrator A | Administrator | Submitted the incident report to SD DOH after delay. |
| Director of Nursing B | Director of Nursing | Involved in reporting process and policy verification. |
| LPN F | Licensed Practical Nurse | Witnessed the medication error and described insulin storage. |
| RN E | Registered Nurse | Described insulin audit procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 21, 2024
Visit Reason
The inspection was conducted following complaints regarding the conduct and professionalism of a certified nursing assistant (CNA N) towards several residents, including concerns about communication, dignity, and resident care.
Complaint Details
The complaint investigation found substantiated issues with CNA N's behavior, including rude and unprofessional conduct, embarrassment of residents, and aggressive attitude. CNA N was removed from the schedule pending investigation.
Findings
The provider failed to ensure communication and resident care were provided in a dignified manner by CNA N, who was reported to be rude, unprofessional, and aggressive towards multiple residents. CNA N was removed from the schedule pending an internal investigation.
Deficiencies (1)
Failure to protect residents from verbal and emotional abuse by CNA N, including rude communication, embarrassment, and lack of respect.
Report Facts
BIMS scores: 15
BIMS scores: 15
BIMS scores: 14
BIMS scores: 11
Residents sampled: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA N | Certified Nursing Assistant | Named in multiple findings of unprofessional and disrespectful conduct towards residents |
| Administrator A | Administrator | Interviewed regarding findings; unaware of issues prior to investigation |
| CEO P | Chief Executive Officer | Interviewed and confirmed incident; involved in decision to remove CNA N from schedule |
| Director of Nursing/Infection Control Nurse B | Director of Nursing/Infection Control Nurse | Mentioned in relation to discussion pending interview with CNA N |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Nov 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, abuse prevention, infection control, and facility operations at Westhills Village Health Care Facility.
Findings
The facility was found deficient in multiple areas including failure to ensure call light accessibility, dignified communication and care, adherence to physician orders, trauma screening, proper food handling and glove use, and infection prevention and control practices.
Deficiencies (6)
Failure to ensure in-room call lights were accessible for two sampled residents.
Failure to ensure communication and resident care were provided in a dignified manner by a certified nursing assistant for five sampled residents.
Failure to follow physician's orders for weight-bearing restrictions and dressing changes for two sampled residents.
Failure to screen two sampled residents for history of trauma upon admission.
Failure to ensure proper glove use and temperature probe cleaning by cook during meal services.
Failure to maintain infection control and prevention practices during wound care, nasal cannula care, and personal care for sampled residents.
Report Facts
Residents affected: 2
Residents affected: 5
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 3
BIMS score: 15
BIMS score: 14
BIMS score: 11
BIMS score: 7
BIMS score: 5
PHQ-2 score: 0
PHQ-2 score: 6
Admission date: 2024
Admission date: 2024
Admission date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA N | Certified Nursing Assistant | Named in findings related to undignified communication and care for multiple residents |
| CNA K | Certified Nursing Assistant | Named in infection control and hand hygiene deficiencies during resident care |
| CNA M | Certified Nursing Assistant | Named in infection control deficiencies during resident care and transfer |
| LPN F | Licensed Practical Nurse | Named in dressing change and infection control deficiencies |
| Cook Q | Cook | Named in glove use and temperature probe cleaning deficiencies |
| Director of Nursing (DON)/Infection Control Nurse B | Director of Nursing/Infection Control Nurse | Interviewed regarding multiple deficiencies and facility policies |
| Registered Nurse H | Registered Nurse | Interviewed regarding resident care and infection control |
| Administrator A | Administrator | Interviewed regarding facility policies and deficiencies |
| Social Services Designee I | Social Services Designee | Interviewed regarding trauma screening and resident social services |
| Social Services Consultant J | Social Services Consultant | Interviewed regarding trauma screening and resident social services |
| Physical Therapist O | Physical Therapist | Interviewed regarding resident mobility and weight-bearing restrictions |
| Food Services Manager D | Food Services Manager | Interviewed regarding food service glove use and temperature probe cleaning |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
Annual survey inspection of Westhills Village Health Care Facility to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 2
Date: Mar 31, 2022
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, specifically focusing on oxygen (O2) administration orders and practices for residents in the nursing facility.
Findings
The facility failed to ensure physician orders for oxygen administration were properly obtained and followed for two sampled residents. Resident 22 used oxygen without a current physician order, and resident 134 received oxygen at flow rates not consistently supported by physician orders. Documentation and communication regarding oxygen use and orders were inconsistent.
Deficiencies (2)
Failure to obtain and follow physician orders for oxygen administration for resident 22.
Failure to have current and accurate physician orders for oxygen flow rates for resident 134, resulting in oxygen administration without proper orders.
Report Facts
Oxygen flow rates administered: 2
Oxygen flow rates administered: 3
Oxygen flow rates administered: 2
Oxygen flow rates administered: 4
Dates of oxygen administration at 2 liters: 4
Dates of interdisciplinary notes: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN F | Registered Nurse | Interviewed regarding resident 22's oxygen use and noted resident refused oxygen on 3/18/22 fax. |
| Administrator A | Administrator | Interviewed regarding oxygen orders and facility policies. |
| Director of Nursing B | Director of Nursing | Interviewed regarding oxygen orders and facility responsibilities. |
| LPN D | Licensed Practical Nurse | Interviewed regarding resident 134's oxygen administration. |
| RN C | Registered Nurse | Interviewed regarding resident 134's oxygen usage and EMAR orders. |
| CNA E | Certified Nursing Assistant | Interviewed regarding oxygen administration practices and CNA responsibilities. |
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