Bethesda Of Beresford
606 W Cedar, Beresford, SD 57004 · Non profit - Corporation · 39 certified beds · (605) 763-2050 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,088 in federal fines (most recent 2023-10-04)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
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
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
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.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 14.5% | 21.3% | 15.4% | typical |
| Long-stay residents who lose too much weight | 0.9% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.4% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 4.3% | 5.7% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.3% | 5.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.7% | 19.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 26.3% | 17.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.3% | 4.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.3% | 25.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.0% | 24.6% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.11 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.86 | 1.75 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 45.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 45.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 45.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 45.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 8.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.20 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 39 beds and averages 34.1 residents a day — about 87% occupied, or roughly 5 beds typically open. It runs fairly full. 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 3.69 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.15 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 is below 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 3.10 hrs/resident/day on weekends vs 3.92 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.19 to 1.06 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 1 administrator has left in the past year.
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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2023-10-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
Based on review of a South Dakota Department of Health facility incident report, interview, observation, policy review, and document review, the provider failed to develop and implement an effective training and orientation program for five of seven certified nurse assistants (CNAs) (C, E, F, G, and H) that might have contributed to an accident involving a full-body mechanical lift falling on top of one of one sampled resident (1) resulting in bodily injury. Findings include: 1. Review of the provider's incident report submitted to the South Dakota Department of Health on 8/24/23 revealed the following: *On 8/24/23 at approximately 7:40 a.m., CNAs E and F were assisting resident 1 from her bed to her wheelchair using the full-body mechanical lift (EZ Way). *Both CNA E and F were contracted staff employed through a staffing agency. *CNA E was controlling the mechanical lift, while CNA F was standing behind the wheelchair and holding onto the resident's sling handles. *CNA F tilted the wheelchair back to maneuver the resident into the wheelchair. *At some point, the full-body…
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.
- Potential for harm · E2026-06-11 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 the South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interviews, record review, and policy review, the facility failed to ensure the implementation of policies and procedures for conducting neurological assessments following unwitnessed falls or potential head injuries for three of six sampled residents (1, 2, and 3). Findings Include:1. Review of the provider's 3/3/26 SD DOH FRI revealed on 3/2/26 at 3:35 p.m., resident 1 was found on his fall mattress (padded mat placed directly on the floor) next to his bed by licensed practical nurse (LPN) D. While assessing resident 1, LPN D and CNA G identified that resident 1's oxygen concentrator (a device that filters room air into purified oxygen) was turned off, although his nasal cannula (NC) tubing (flexible tubing that delivers oxygen through the nose) was on the resident and attached to the concentrator. Resident 1 had a physician's order to receive oxygen continuously at a rate of 3 liters (L) per minute. His oxygen…
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.
- Potential for harm · Dcited before2026-06-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 the South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interviews, record review, and policy review, the facility did not adequately implement policies and procedures to ensure proper supervision and safe use of required oxygen equipment. This failure resulted in one of one sampled resident (resident 1) being left without prescribed oxygen for one hour and fifty five minutes, identified by him falling out of bed on 3/2/26. When Licensed Practical Nurse (LPN) D assessed the resident, his oxygen saturation level was 60%. Findings include:1. Review of the provider's 3/3/26 SD DOH FRI revealed on 3/2/26 at 3:35 p.m., resident 1 was found on his fall mattress (padded mat placed directly on the floor) next to his bed by licensed practical nurse (LPN) D. While assessing resident 1, LPN D and CNA G identified that resident 1's oxygen concentrator (a device that filters room air into purified oxygen) was turned off, although his nasal cannula (NC) tubing (flexible tubing 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.
- Potential for harm · Ecited before2025-08-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
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 observation, interview, record review, policy review, and manufacturer's guideline review, the provider failed to ensure:*Oxygen equipment for two of two sampled residents (3 and 28) who required the use of supplemental oxygen was kept off the floor and appropriately serviced.*Infection control practices had been followed by three of three staff members (registered nurse (RN) J, certified nursing assistant (CNA) K, and CNA L) to minimize the risk of contamination to the oxygen tubing, for one of one sampled resident's (3) who required the use of continuous oxygen.*One of one sampled resident (3) received oxygen as ordered by the physician.*One of one sampled resident's (28) continuous use of oxygen at night was addressed in the resident's care plan. Findings include:1. Observation and interview on 8/12/25 at 9:05 a.m. with resident 3 while he was in his bed in his room revealed:*He communicated with sounds and gestures.*He had an oxygen (O2) concentrator (a device that filters room air into purified…
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.
- Potential for harm · Ecited before2025-08-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 Based on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure:*Documentation was completed consistently for two of two weekly scheduled cleaning tasks of the kitchen.*Temperature monitoring and documentation was completed consistently for one of one coffee machine.*One of one dietary aide (O) had washed her hands before and after serving and touching resident food items to prevent potential contamination.Findings include:1. Observation on 8/11/25 at 1:50 p.m. in the kitchen revealed:*A binder containing the weekly kitchen cleaning schedules.*The binder indicated staff needed to initial a task when it was completed. *On the 8/4 - 8/10 weekly cleaning schedule 13 out of the 40 listed tasks were not marked complete.*On the 7/28-8/3 weekly cleaning schedule 14 out of the 40 listed tasks were not marked complete. 2. Observation on 8/11/25 at 2:45 p.m. in the dining room revealed:*A coffee machine on the counter by the kitchen doorway.*There was a…
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.
- Potential for harm · Dcited before2025-08-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, observation, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (40) who eloped (left the facility without staff knowledge).Findings include:1. Review of the provider's 7/9/25 submitted SD DOH FRI regarding resident 40 revealed:*On 7/9/25 at 1:44 p.m. resident 40 was found on the east side of the building by certified nursing assistant (CNA) M.*CNA M brought her back into the facility and notified the registered nurse (RN) N.*Staff determined she had exited the facility through the east door in the therapy department.*The door leading into the therapy department had been propped open and the east door leading to outside was unalarmed.*She did not recall leaving the facility and her vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) were within normal limits.*Therapy staff were educated…
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.
- Potential for harm · Dcited before2025-08-13 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 Based on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed by failing to place one of one sampled resident (23) with an open surgical wound on his ear on enhanced barrier precautions (EBP) (gloves and gown use when providing contact care).Findings include: 1. Observation on 8/11/25 at 3:38 p.m. of resident 23 in the hallway revealed there was a bandage on his right ear that appeared to be soaked with blood. Record review of resident 23's electronic medical record (EMR) revealed:*He was admitted to the facility on [DATE].*He had a diagnoses of squamous cell carcinoma (a type of skin cancer originating from the outer layer of the skin) of the skin of the right ear and the external auricular (ear) canal. *He had seen a dermatologist to remove the area of skin cancer on his right ear.*His power of attorney (POA) (someone designated on a legal document to act on behalf of a resident) was informed that the surgical wound on his right ear…
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.
- Potential for harm · E2024-08-08 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and policy review, the provider failed to ensure a Bed Hold Notice form was given to four of four sampled residents (1, 2, 3, and 4) prior to transfer to the emergency departmentl. Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed: *She required an emergency room evaluation on 4/4/24. *Resident 1 was hospitalized for nausea/vomiting and stomach pain. *Her emergency contact had been notified on 4/4/24 of the need for an emergency room evaluation. *There had not been any documentation found regarding notification of the resident's bed hold. 2. Review of resident 2's EMR revealed: *She required an emergency room evaluation on 6/20/24. *Resident 2 was hospitalized for gastrointestinal bleeding. *Her power of attorney (POA) was notified on 6/20/24 of the need for an emergency room evaluation. *There had not been any documentation found regarding notification of the resident's bed hold. 3. Review of resident 3's EMR revealed: *She required an emergency room evaluation on 3/24/24. *Resident 3 was hospitalized for sepsis…
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.
- Potential for harm · F2024-04-25 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 observation, interviews, record review, and policy review, the provider failed to ensure there were sufficient nursing staff to ensure call lights were answered in a reasonable time for five of thirty-five sampled residents (3, 4, 5, 13, and 21). Findings include: 1. Interview on 4/23/24 at 10:29 a.m. with resident 4 in his room revealed he: *Pointed out his pendant call light and stated its function. *Mentioned that sometimes he had to wait 20 to 30 minutes for someone to answer the call light. *Did not use the call light frequently. Review of resident 4's call light audit report from 2/24/24 to 4/24/24 revealed: *The report was generated from 2/24/24 to 4/24/24, but there was no data on the report before 4/5/24. *There were three call light wait times over 15 minutes. *The longest call light wait time was 40 minutes. 2. Interview on 4/23/24 at 11:01 a.m. with resident 3 about call light wait times revealed that she noticed she had to wait longer at nighttime. Review of resident 3's call light audit…
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.
- Potential for harm · Fcited before2024-04-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
Based on observation, interview, record review, and policy review, the provider failed to ensure necessary food safety guidelines were implemented and followed for appropriate storage and labeling of food and chemical items, appropriate monitoring of the low-temperature dishwasher, and cleaning and sanitary maintenance of one of one kitchen. Findings include: 1. Observation on 4/23/24 at 8:26 a.m. during the initial kitchen tour revealed: *There were approximately 35 cans of fruits and vegetables in the dry storage room with no manufacturer's date and no date when those food items were received. *There were four dented cans in the dry storage room. *The chemical sanitizer monitoring sheet for the low-temperature dishwasher was missing concentration measurements for the following dates: 4/2/24, 4/6/24, 4/7/24, 4/9/24, 4/12/24, 4/16/24 4/19/24, 4/20/24, 4/21/24, and 4/23/24. *The chlorine testing strips for testing the dishwasher chemical sanitizer concentration had an expiration date of September 1, 2023. *A bottle of liquid bleach disinfecting cleaner and two spray bottles 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.
- Potential for harm · F2024-04-25 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Certification and Survey Provider Enhanced Reports (CASPER) data review, staff schedule and timecard review, and interview, the provider failed to ensure Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the care of the residents) data was accurately completed before submission to the Center for Medicare and Medicaid Services (CMS) for three of four federal fiscal quarters (Quarter 2, 2023; and Quarter 3, 2023; and Quarter 1, 2024). Findings include: 1. Review of the PBJ data submitted to CMS for the three quarters listed above revealed: *The following items were triggered: -Excessively low weekend staffing (Quarter 3, 2023 only). -Failed to have licensed nursing coverage 24 hours per day. *The infraction dates for failing to have licensed nursing coverage 24 hours per day was as follows: -Quarter 1, 2024 (October 1, 2023, to December 31, 2023): 10/7/23, 10/16/23, 11/18/23, 11/23/23, 11/27/23, 12/9/23, 12/16/23, 12/19/23, 12/23/23, 12/25/23, and 12/26/23. -Quarter 3, 2023 (April 1, 2023, to June 30, 2023): 4/1/23, 4/5/23, 4/6/23, 4/7/23,…
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.
Show the remaining 16 citations
- Potential for harm · Fcited before2024-04-25 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and policy review, the provider failed to ensure that Legionella monitoring and prevention were addressed in the infection control program, which had the potential to affect all 35 residents within the facility. Findings include: 1. Review of the provider's 10/27/21 infection prevention and control program revealed there was nothing related to the prevention and monitoring of Legionella. 2. Interview on 4/25/24 at 8:15 a.m. with administrator A about the provider's Legionella program revealed: *She was not aware of any water testing for Legionella. *Director of nursing B was the infection preventionist, but she was not present in the facility for an interview. *Maintenance director D might know more about the Legionella monitoring. Interview on 4/25/24 at 11:31 a.m. with maintenance director D about Legionella revealed: *He did not perform any testing on the facility's water supply. *They were connected to the city's municipal water system. *He contacted the city's municipal water department and learned they did not monitor for Legionella. -They only monitored the…
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.
- Potential for harm · E2024-04-25 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 observation, interview, and record review, the provider failed to ensure a clean and homelike environment was maintained in the following areas: *The activities room. *Resident rooms (1, 4, 5, 9, 13, 17, and 22). *The surfaces of the mechanical lifts. *The hand sanitizer dispensers. *The scale room. Findings include: 1. Observation on 4/23/24 at 8:13 a.m. in the activities room revealed: *There were glitter and confetti pieces on the tables and on the floor. *The counters were cluttered with several art and craft supplies that had not been put away (paper, puzzles, games, painting supplies, potting soil, crayons, colored pencils, markers). *There were dust bunnies, dead leaves, and dirt particles on the floor throughout the room. 2. Observation on 4/23/24 at 8:36 a.m. in the scale room revealed: *The carpet had stained spots throughout the room. *There were bits of what appeared to be torn paper scattered on the floor. *The scale itself had flakes of an unidentified white material and was missing pieces…
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.
- Potential for harm · Ecited before2024-04-25 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, admission packet review, policy review, and plan of correction review, the provider failed to: *Make information available on how to file a grievance and the location of the grievance forms readily available to residents and their representatives. *Designate who the grievance official was. Findings Include: 1. Interview with the resident council on 4/24/24 from 1:00 p.m. through 1:35 p.m. revealed: *The residents were not aware of who the grievance official was. *The residents were not aware how to file a grievance or where to find the necessary forms. Observation of the lobby and the public area in the center of the facility around the nursing station on 4/24/24 at 1:40 p.m. and again on 4/25/24 at 2:16 p.m. revealed the grievance official contact information, how to file a grievance, and the grievance forms were not in prominent locations that would be readily available to anyone with a grievance. Interview on 04/25/04 at 2:08 p.m. with administrator A revealed: *She was the grievance official and handles all the paperwork. *It was her expectation…
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.
- Potential for harm · Ecited before2024-04-25 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the provider failed to ensure expired medications were not administered to residents, and removed and discarded for nine of thirty bulk medications in two of two medication carts. Findings include: 1. Observation on 4/25/24 at 10:20 a.m. of the 200/300 hallway medication carts with licensed practical nurse (LPN) F revealed there were several bulk medications that were past the manufacturer's expiration dates: *A bottle of Senna with an open date of 8/6, and an expiry date of 1/2024. *A bottle of TUMS, there was no open date or expiry date noted. *A bottle of multivitamins with an open date of 2/10/23 and a Best if Used By date of 3/2024. *A bottle of calcium tablets with an open date of 12/29/22, and an expiry date of 12/22/23. *A bottle of aspirin with an open date of 8/26/23 and an expiry date of 2/2024. 2. Observation on 4/25/24 at 10:55 a.m. of the 100/400 hallway medication cart with registered nurse K revealed: *An open bottle of TUMS, there was no open date, the expiry date was 6/2025. *An opened bottle 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.
- Potential for harm · E2024-04-25 · tag F0909 — failed to maintain a comfortable temperature — patternRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the provider failed to ensure the regular safety inspection of bed rails for two of two sampled residents (2 and 7). Findings include: 1. Observation and interview on 4/23/24 at 8:49 a.m. with resident 7 revealed: *She had bed rails on the bed in the up position. -She stated she had a stroke 5 years ago and could not use her right leg or arm. -She said she used the bed rails sometimes for repositioning, otherwise, they are just there. Interview with CNA X revealed: *Resident 7 used thebed rail at night, but she never observed her using them. 2. Observation and interview on 4/23/24 at 9:24 a.m. with resident 2 revealed: *She was sitting in her wheelchair in her room while CNA Y made her bed. *Resident 2 would not respond when questioned about the use of the rail. -There was one bed-rail on her bed that was near the wall. -CNA Y stated the resident did not use the bed rail. 3. Interview on 4/25/24 at 10:15 a.m. with maintenance director D revealed he: *Did not assess the bedrails. -Did not have measurements or any log…
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.
- Potential for harm · E2024-04-25 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
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 observation, resident and family interview, call light audit review, and policy review, the provider failed to ensure the resident call light system was functioning for 2 of 13 sampled residents (5 and 13) out of 35 total residents. Findings include: 1. Observation and interview on 4/23/24 between 11:34 a.m. and 11:41 a.m. with resident 5 in her room revealed: *At times she waited hours at night for someone to assist her when she used her call light. *The blue call button was pushed at 11:41 a.m. -The red indicator light was not activated. -There was no indication outside the room that the resident's call light was on. Observation and interview on 4/23/24 at 11:48 a.m. with certified nurse assistant (CNA) Y revealed: *She walked past resident 5 ' s room for a second time. *When asked if resident 5 ' s call light was activated, she stated that the call light was not currently activated on her walkie [walkie-talkie]. -She carried the walkie [walkie-talkie] in her pocket, and it audibly announced which…
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.
- Potential for harm · D2024-04-25 · tag F0575 — isolatedPost a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and review of the resident admission packet, the provider failed to ensure the ombudsman and South Dakota Department of Health (SD DOH) contact information had been posted in a location accessible to all 35 current residents, visitors, and families. Findings include: 1. Interview with the resident council on 4/24/24 from 1:00 p.m. through 1:35 p.m. revealed the residents were: *Unaware where to find contact information for the ombudsman (resident advocate). *Not aware they could contact the SD DOH directly or file a complaint with the SD DOH. 2. Observation on 4/24/24 at 1:40 p.m. and again on 4/25/24 at 2:16 p.m. revealed the following: *The ombudsman contact information was posted in the entryway vestibule and the social worker's office. -In the entryway vestibule, the information was posted at standing-eye-level and required a door code to access the area. -In the social worker's office, there was a poster on the wall above the bookshelf. It was posted near the ceiling. The social worker's office was not always accessible to the residents. *There…
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.
- Potential for harm · D2024-04-25 · tag F0577 — isolatedAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview, observation, and policy review, the provider failed to make the most recent survey results accessible to all residents and their representatives. Findings include: 1. Interview with the resident council on 4/24/24 from 1:00 p.m. through 1:35 p.m. revealed the residents were unaware of their right to read the state survey results or where to find them. Observation of the lobby and public areas on 4/24/24 at 1:40 p.m. and again on 4/25/24 at 2:16 p.m. revealed the survey results had not been made available. Interview on 04/25/04 at 2:08 p.m. with administrator A confirmed: *The survey results were not currently posted. *The survey binder had been removed from the front lobby in January 2024 after a water leak. Review of the facility resident rights document in the admission packet provided to residents revealed the right to .examine the results of the most recent survey of [provider's name] conducted by Federal or State surveyors and any plan of correction in effect. Results are located at the nurses' station and next to the business office.
- Potential for harm · D2024-04-25 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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, interview, and policy review, the provider failed to implement a revised advanced directive for one of sixteen sampled residents (32) reviewed for advance directives. Findings include: 1. Review of resident 32's paper and electronic medical record (EMR) revealed: *The dashboard indicated full code. (Individual desire for cardiopulmonary resuscitation [CPR] to be initiated if their heart stopped.) *The physicians' order dated [DATE] indicated full code. *The care conference notes dated [DATE] indicated Code status was changed from Full Code to DNR [do not resuscitate]. Provider was faxed. Interview on [DATE] at 11:06 a.m. with administrator (ADM) A revealed: *It was her expectation that staff would look at the EMR dashboard to find a resident's current code status. *She recalled the power of attorney (POA) changed resident 32's code status at the last care conference that was held on [DATE]. *She stated, I should have followed up with a new Expressions of Healthcare Preferences form. *It…
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.
- Potential for harm · D2024-04-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 observation, interview, record review, and policy review, the provider failed to develop, revise, and implement a comprehensive person-centered care plan that addressed nail care and range of motion for two of fourteen sampled residents (3 and 5). Finding Include: 1. Observation and interview on 4/23/24 at 9:19 a.m. with resident 3 revealed: *There was a picture on the wall with instructions on how to put on a right-hand splint and a schedule for the times that the splint was to have been put on. *Resident 3 indicated she had not worn that splint for a long time. *She rested her right hand in her lap. *When asked to lift her arms she was unable to lift her right arm. *She stated, No, none, when asked about range of motion exercises and if anyone helped her to move her arms. *She indicated that she: -Had been in therapy but was not currently. -Wanted an exercise program for her right arm. Interview on 4/24/24 at 2:35 p.m. with registered nurse (RN) N revealed that resident 3 only wore the hand splint at…
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.
- Potential for harm · D2024-04-25 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the provider failed to ensure an ongoing restorative nursing program for two of two sampled residents (3 and 5) at risk for a decline in range of motion. Findings include: 1. Observation and interview on 4/23/24 at 9:19 a.m. with resident 3 revealed: *There was a picture on the wall with instructions on how to put on a right-hand splint and a wearing schedule for that splint. -Resident 3 indicated she had not worn that splint for a long time. *She rested her right hand in her lap. *When asked to lift her arms she was unable to lift her right arm. *She stated, No, none, when asked about range of motion exercises and if anyone helped her to move her arms. *She indicated that she: -Had been in therapy but was not currently. -Wanted an exercise program for her right arm. Review of resident 3's paper and electronic medical record (EMR) revealed: *An admission date of 5/24/22. *Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and contracture of muscle; right…
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.
- Potential for harm · Fcited before2023-10-04 · tag F0585 — failed to handle grievances — widespreadHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 interview, observation, and policy review, the provider failed to implement an effective grievance process to ensure a resident's right to file grievances included documentation, investigation, and follow-up with the resident and the resident's representative's grievances regarding issues of resident care and quality of life that were important to the resident. That failure had the potential to affect all 35 residents. Specifically, the provider failed to ensure the following: *Information on how to file a grievance or complaint was available to the resident and their representative and posted in a prominent location. *The right to file a grievance, orally or in writing, the right to file grievances anonymously, the contact information of the grievance official with whom a grievance could have been filed, a reasonably expected time frame for completing the review of the grievance, and the right to obtain a written decision regarding his or her grievance. *The Grievance Official was clearly identified…
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.
- Potential for harm · F2023-04-05 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and job description review, the provider failed to employ a qualified nutritional professional to serve as the dietary manager. Findings include: 1. Interview on 4/3/23 at 3:00 p.m. with [NAME] F. during the initial kitchen tour revealed: *They currently had no dietary manager. *The administrator had been filling the position until someone could be hired. *It had been many months since they had a dietary manager on staff. Interview on 4/4/23 at 4:16 p.m. with administrator A revealed: *The last dietary manager had left in early October 2022. -She had worked as the CDM a few months, left for maternity leave, and put in her notice when she returned after her maternity leave ended. *They had recruited for the open dietary manager position but were not successful in getting someone hired. *She confirmed awareness that she had been required to have education and training if she served in the dietary manager position. *She had not enrolled in or started a dietary manager training program. *She was not Serv Safe certified. *None of the cooks or dietary staff had been…
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.
- Potential for harm · Ecited before2023-04-05 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the provider failed to ensure: *Four of four sampled residents (1, 5, 19, and 36) scheduled IV controlled medications had been counted and secured under a double lock system. *One of one medication refrigerator had the proper interventions documented for out of range temperatures. Findings include: 1. Observation and interview on 4/5/23 2:30 p.m. with director of nursing (DON) B revealed: *Schedule IV controlled medications in two of two medication carts (100/400 and 200/300) included: -Alprazolam 0.5 milligram (mg) 17 tablets for resident 19. -Clonazapam 0.5 mg 4 tablets for resident 36. -Lorazepam 0.5 mg 31 tablets for resident 5. -Temazepam 30 mg 9 capsules resident 1. *DON B confirmed those scheduled IV controlled medications were not kept in the locked controlled substance compartment in the medication carts. Those medications had not been included in the nurses- controlled medication counts. Review of the provider's 3/3/15 Controlled Substances policy requirements for storage and documentation only applied to…
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.
- Potential for harm · Ecited before2023-04-05 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
Based on observation, interview and policy review, the provider failed to: *Ensure appropriate glove use during the meal preparation and food service by one of one cook (F) during one of one observed meal service. *Maintain the cleanliness of the exhaust fans in one of one walk-in cooler. 1. Observation on 4/3/23 at 4:15 p.m. through 5:15 p.m. during food preparation and meal service with cook F revealed: *She washed her hands with soap and water, dried them, and put on a pair of gloves. *Foods were taken out of the oven and placed on the steam table for the meal service. *Grilled cheese had been on the menu. *There had been a stack of buttered slices of bread on a wooden cutting board on the food preparation table. *A plastic container with slices of cheese was next to the cutting board. *She began to assemble the grilled cheese and placed them on the hot cooktop grill. *The cheese container was returned to the cooler. *At 4:39 p.m. she walked over to a kitchen drawer and opened it with her gloved hands to retrieve a serving tool. -She went to the cooktop grill, removed one of the…
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.
- Potential for harm · D2023-04-05 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 observation, interview, medical record review, and policy review, the provider failed to assess for the need for bed rails for one of five sampled residents (36). Findings include: 1. Observation and interview on 4/3/23 at 4:30 p.m. with resident 36 in her room revealed she: *Was admitted about one month ago. *Had bilateral quarter bed rails on her bed. -She said the bed rails were on the bed when she was admitted . *Used the bed rails to reposition herself. 2. Interview on 4/5/23 at 10:23 a.m. with director of nursing B about bed rails revealed: *When a resident was discharged , she would submit a work order for maintenance to remove the bed rails in preparation for a new resident. *Before they would install bed rails, they would submit a request to the resident's physician to order a bed rail assessment. *If the bed rail assessment revealed the resident would benefit from bed rails, they would have completed the following steps: -Educated the resident and their representatives about bed rail use 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.
“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.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$16,088 in federal fines across 1 penalty.
- $16,088 — penalty dated 2023-10-04
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BETHESDA OF BERESFORD | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 11/19/2009 |
| HANSEN, CHRIS | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/14/2021 |
| CHADWELL, DEAN | Individual | CORPORATE DIRECTOR | — | since 05/01/2023 |
| SAVEY, AMELIA | Individual | CORPORATE DIRECTOR | — | since 05/01/2023 |
| CARING PROFESSIONALS INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/14/2021 |
| ROHLFS, KARSTEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2024 |
| SENGER, BRITNEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/28/2021 |
CMS files one row per role, so the 13 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in SD
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the South Dakota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 435080. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.