Oglala Sioux Lakota Nursing Home

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

How full it usually is: this home is certified for 72 beds and averages 37.1 residents a day — about 52% occupied, or roughly 35 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.77 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.54 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.89 hrs/resident/day on weekends vs 7.12 on weekdays — 17% thinner on weekends. RN hours go from 2.01 to 1.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

20 citations, most serious first. The 11 most serious are shown; the remaining 9 are one tap away and print in full.

• Actual harm · G2024-09-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Licensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on observations, interviews, and record reviews; the facility failed to implement new interventions to prevent significant weight loss for 1 (Resident 20) of 4 sampled residents. The facility census was 47. Findings are: A record review of a facility policy Weight Assessment and Intervention with a revision date of March 2022 revealed the following: -Weight loss of 7.5% in three months is considered significant. A weight loss of greater than 7.5% is considered severe. -Weight loss of 10% over six months is considered significant. A weight loss of greater than 10% over six months is considered severe. -Care planning for weight loss is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. -Individualized care plans shall address the identified causes of weight loss, goals, and timeframes for monitoring and reassessment. A record review of Resident 20's quarterly Minimum Data Set (a federally mandated comprehensive…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-12-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, record review, and interview; the facility failed to dispose of foods by their best by dates and failed to store the scoops for the flour, breadcrumbs, and sugar in a manner to prevent the potential for cross contamination. This had the potential to affect all residents who ate foods prepared in the kitchen. The facility census was 36.A.A record review of the 2022 Food Code from the United States Food and Drug Administration revealed in Annex 3 that it is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. An observation on 12/15/2025 at 9:56 AM in the dry storage area of the kitchen revealed: -A jug of apple cider vinegar that was half empty, labeled best if used by 12/4/25, and-A plastic container labeled Barley and had a use by date of 10/29/25. An interview on 12/15/2025 at 10:10 AM with the Dietary Manager (DM) confirmed the two items were beyond their use by dates and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-17 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to submit their investigation within 5 working days for 1 (Resident 41) of 3 sampled residents' fall with injury. The facility census was 36. A record review of the facility's undated Abuse Prevention Policy revealed a written report will be provided to the State within five working days of the Administrator receiving the report. A record review of an undated, facility provided document titled List of Reportables revealed there had been a fall with injury on 10/26/2025. A record review of Resident 41's Progress Note dated 10/26/2025 revealed the resident had a fall with a laceration to their forehead and a skin tear to their left elbow that day. The resident was sent to the emergency room and returned to the facility the same day with sutures to their forehead. A record review of an untitled facility-provided document revealed details of Resident 41's fall that occurred on 10/26/2025. The document revealed Today's Date was 11/3/2025, which was 6 working days after the incident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-17 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to submit accurate Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) for 2 (Residents 6 and 32) of 12 sampled residents. The facility identified a census of 36 residents. A. A record review of Resident 6's care plan in Point Click Care (PCC- an electronic medical record platform) revealed Resident 6 was admitted [DATE].Record review of Resident 6's annual MDS assessment dated [DATE], Section K, item K0200 Resident's most recent weight was given as 132 pounds. Item K0300 was marked yes for weight loss and, the resident was not on a physician-prescribed weight-loss regimen. Weight loss was further defined in MDS Item K0300 as 5% or more in the last month or 10% or more in the last six months.Record review of Resident 6's weights as documented in the facility's electronic medical record (EMR) showed Resident 6 weighed 132…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.006.09(I)(i)(3) Based on record review and interviews, the facility failed to implement interventions to prevent falls for 3 (Residents 1, 2, and 3) of 3 sampled residents. The facility census was 42. Findings Are: A record review of facility policy Falls-Clinical Protocol, with a revision date of March 2018 revealed that for an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. The policy also stated that based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-09-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews, and record reviews; the facility failed to ensure foods were disposed of or consumed prior to best-by and use-by dates, and failed to ensure food practices were conducted as required to prevent the potential for foodborne illness. This had the potential to affect all 47 residents who resided within the facility and ate foods prepared in the kitchen. A. An initial kitchen tour observation on 9/9/2024 at 9:16 AM revealed the following: In the dry food storage area: -Eleven 32-ounce containers of [NAME] Ready-care no sugar added 1.7 high calorie high protein nutrition drink with best by date of 5/7/24. -Three 4-ounce cups of 'Gelatein 20' high protein gelatin with an expiration date of 7/20/24. -Fourteen 28-ounce packets of Jell-O brand dry chocolate pudding mix with an expiration date of 6/12/24. -Twelve 4-ounce cups of prune juice, with a best by date of 7/3/24. -Forty 4-ounce cans of [NAME] nacho cheese dip with a best by date of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-09-12 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Licensure Reference Number 175 NAC 12-006.10(D) Based on observations, interviews, and record review; the facility failed to administer medication at the right time and to ensure the medication error rate was less than 5% for 3 (Residents 11, 43, and 98) out of 5 sampled residents. The medication error rate was 35.71%. The facility census was 47. Findings are: A record review of a facility policy Administering Medications with a revision date of April 2019 indicated medications are to be administered within one hour of their prescribed time. A record review of Resident 98's Medication Administration Record with a date of September 2024 revealed an order for cephalexin, an antibiotic, with a prescribed time of 7:00 AM. An observation on 9/11/2024 at 8:20 AM revealed Medication Aide (MA) - H had administered Resident 98's cephalexin at this time. A record review of Resident 43's Medication Administration Record with a date of September 2024 revealed orders for Miralax and omeprazole, both with prescribed times of 7:30 AM. An observation on 9/11/2024 at 8:48 AM revealed MA-H had…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-09-12 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18(B); 12-006.18(D) Based on observations, record reviews, and interviews, the facility failed to ensure a PAP (Positive Airway Pressure-a machine that delivers just enough air pressure to a mask worn over the nose or mouth to keep the upper airway passages open) mask was cleaned per facility policy to prevent infection for 1 (Resident 2) of 2 sampled residents for respiratory care, failed to implement enhanced barrier precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes. EBP involves wearing a gown and gloves during high-contact resident care activities, such as wound care, for residents known to be colonized or infected with a MDRO as well as residents at increased risk of MDRO acquisition [for example, residents with wounds or indwelling medical devices]) for 1 (Resident 22) of 2 sampled residents for pressure injury, and the facility failed to ensure hand hygiene was performed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-12 · tag F0623 — isolated
  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05 Nebraska State Statute 71-6023 Based on record review and interview, the facility failed to ensure the required information was included in the written notice of transfer for Resident 8 upon transfer to the hospital. This affected 1 of 1 resident sampled for hospitalization. The facility census was 47. Findings are: A record review of Resident 8's admission Record printed on 9/12/2024 revealed the resident was admitted to the facility on [DATE] and had a primary diagnosis of dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities). A record review of Resident 8's Clinical Census printed on 9/10/2024 revealed the resident was transferred to the hospital on 8/16/2024 and returned to the facility on 8/17/2024. A record review of Resident 8's Notice of Resident Transfer or Discharge dated 8/16/2024 provided by the facility revealed the following: -Resident 8's name was not on the form. -Under the section The reason…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-12 · tag F0637 — isolated
  Assess the resident when there is a significant change in condition
  What the surveyor found here — an excerpt from the official record, may be distressing

  Licensure Refence 175 NAC 12-006.09(C)(ii) Based on interview and record reviews, the facility failed to complete a significant change Minimum Data Set (MDS, a federally mandated comprehensive assessment that includes medical, psychosocial, cognitive, and functional status to assist with developing care plans for individual resident) for 1 (Resident 20) of 12 sampled residents. The facility identified a census of 47 at the time of the survey. Findings are: A record review of a facility policy Change in a Resident's Condition or Status with a revision date of February 2021 revealed the following: -A significant change of condition is a major decline in the resident's status that impacts more than one area of the resident's health status. -If a significant change of condition occurs, a comprehensive assessment will be conducted as required by current Omnibus Budget Reconciliation Act (OBRA) regulations and as outlined in the Resident Assessment Instrument (RAI) Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-12 · tag F0640 — isolated
  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete and transmit a Discharge Minimum Data Set (MDS-a federally mandated comprehensive assessment of each resident's functional capabilities) for Resident 8 upon hospitalization. This affected 1 of 1 resident sampled for discharge. The facility census was 47. Findings are: A record review of Resident 8's admission Record printed on 9/12/2024 revealed the resident was admitted to the facility on [DATE] and had a primary diagnosis of dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities). A record review of Resident 8's Clinical Census printed on 9/10/2024 revealed the resident was transferred to the hospital on 8/16/2024 and returned to the facility on 8/17/2024. A record review of Resident 8's Progress Notes printed on 9/12/2024 revealed a note from 8/16/2024 at 3:49 PM that stated, Resident to be admitted into [hospital]. Further review revealed a note from 8/17/2024 at 11:30 AM that…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in NE