Diamond Care Center
901 N Main Ave, Bridgewater, SD 57319 · For profit - Corporation · 36 certified beds · (605) 729-2525 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
- it has 2 actual-harm citations
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $69,512 in federal fines (most recent 2024-06-21)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 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 — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 fell from 2 to 1 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 | 21.4% | 21.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.5% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.7% | 2.1% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 5.7% | 6.5% | check this* — see note marked star below the table |
| 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 | 10.8% | 5.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.5% | 19.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.0% | 17.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 93.5% | 96.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.3% | 4.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 16.9% | 25.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.1% | 24.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.8% | 2.0% | 1.4% | worse |
| Short-stay residents rehospitalized after admission | 6.4% | 19.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 5.0% | 12.0% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.13 | 1.52 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.51 | 1.75 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
47.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 78.3% 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 23 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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 | 47.5%CMS range 33.1–62.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.5–16.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 78.3% | 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 | 65.2% | 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 | 73.9% | 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 | 3.6% | 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 | 3.6% | 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 | 7.3%CMS range 3.9–11.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 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 36 beds and averages 30.1 residents a day — about 84% occupied, or roughly 6 beds typically open. It usually has some room. 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 2.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 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 2.18 hrs/resident/day on weekends vs 2.55 on weekdays — 15% thinner on weekends. RN hours go from 0.49 to 0.07 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as 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.
25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · G2024-06-21 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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), observations, interviews, and record review, the provider failed to ensure: *One of one sampled resident (10) who was mentally incapable of identifying safety risks was free from the potential of abuse and neglect by one of one sampled resident (37). *One of one sampled resident (1) received necessary care related to pressure ulcers. Findings include: 1. Review of the provider's 6/14/24 submitted SD DOH FRI revealed: *On 6/13/2024 at 12:58 p.m. a suspicion/allegation of abuse/neglect regarding resident-to-resident inappropriate sexual behavior involving resident 10 and resident 37. *At 9:01 p.m. licensed practical nurse (LPN) O contacted administrator (ADM) A and informed her of the incident between resident 10 and resident 37. *Resident 10 was found in resident 37's room in her wheelchair next to resident 37 when certified nursing assistant (CNA) E walked by his room and saw resident 10 sitting in there. *CNA E: -Removed…
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.
- Actual harm · G2024-06-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 a review of the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), record review, interview, and observation, the provider failed to ensure two of two sampled residents (1 and 4) received necessary care and treatment in a timely manner for the prevention of pressure ulcers. Findings include: 1. Review of the provider's 6/10/24 SD DOH FRI revealed: *On 6/10/24 at 12:36 p.m. hospice registered nurse (RN) L contacted interim director of nursing (IDON) G and informed her that resident 1 had open sores on her buttocks. -Dressings had been provided on 6/7/24 by hospice to the provider's staff. -The provider's staff did not use the dressings for resident 1 as they just put her in wheelchair and applied cream to buttocks. -Hospice RN H spoke with the provider's licensed practical nurse(LPN) I and stated to apply the dressing once resident 1 was placed back into her bed. *On 6/10/24 after the conversation between hospice RN L and IDON G, IDON G notified resident 1's family that she 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.
- Potential for harm · F2025-09-11 · 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
Based on Certification and Survey Provider Enhanced Reports (CASPER) data review, staff timecard and pay stub review, facility assessment review, and interview, the provider failed to have licensed nursing coverage for 24-hours per day in the facility for four of four federal fiscal quarters (Quarter 1, 2024, Quarter 2, 2025, Quarter 3, 2024, and Quarter 4, 2024).Findings include:1. Review of the Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the appropriate care of the residents) data for Quarter 1 (October, November, and December 2024) revealed:*There was no 24-hour nursing coverage documented for seventeen days (October 1, 3, 4, 5, 6, 7, 8, 12, 13, 16, 17, 21, 22, 25, 26, 27, and 31) in October 2024.*There was no 24-hour nursing coverage documented for twenty days (November 4, 5, 8, 9, 10, 11, 14, 15, 16, 18, 19, 21, 23, 24, 25, 26, 27, 28, 29, and 30) in November 2024.*There was no 24-hour nursing coverage documented for eighteen days (December 1, 3, 4, 6, 7, 8, 12, 13, 14, 17, 19, 21, 23, 24, 26, 27, 28, and 29) in December 2024. 2. Review…
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 before2025-09-11 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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 timecard and pay stub review, facility assessment review, and interview, the provider failed to ensure a registered nurse (RN) was in the facility for eight consecutive hours daily for four of four federal fiscal quarters (Quarter 1, 2024, Quarter 2, 2025, Quarter 3, 2024, and Quarter 4, 2024).Findings include:1. Review of the Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the appropriate care of the residents) data for Quarter 1 (October 2024 - December 2024) revealed:*There was no eight-hour nurse coverage documented for seven days (October 12, 13, 19, 20, 25, 26, and 27) in October 2024.*There was no eight-hour nurse coverage documented for thirteen days (November 2, 3, 8, 9, 10, 16, 24, 25, 26, 27, 28, 29, and 30) in November 2024.*There was no eight-hour nurse coverage documented for eleven days (December 1, 7, 8, 15, 21, 22, 23, 24, 27, 28, and 29) in December 2024. 2. Review of the PBJ data for Quarter 2 (January 1 2024- March 31 2025) revealed:*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 · Fcited before2025-09-11 · 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 timecard and pay stub review, and interview, the provider failed to ensure Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the appropriate care of the residents) data was submitted to the Centers for Medicare and Medicaid (CMS) for one of four federal fiscal quarters (Quarter 3, 2024). Findings include: 1. Review of the PBJ data submitted to CMS for Quarter 3, 2024 revealed no PBJ data had been submitted to CMS for the time period of April 1, 2024 through June 30, 2024.*The following metrics were suppressed for invalid data:-Excessively Low Weekend Staffing.-No registered nurse (RN) hours.-Failed to have licensed nursing coverage 24 hours per day. Review of the staff timecards and pay stubs revealed licensed nursing coverage for 24-hours a day and RN coverage for seven days a week could not be verified. Interview on 9/11/25 at 2:08 p.m. with administrator A revealed:*She was responsible for submitting the PBJ data report to CMS.*She had not submitted the PBJ…
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 · E2025-09-11 · tag F0813 — patternHave a policy regarding use and storage of foods brought to residents by family and other visitors.
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 monitor refrigerator temperatures to ensure safe food storage for six of six sampled residents (13, 14, 20, 29, 30, and 31) with refrigerators in their rooms.Findings include: 1. Observation and interview on 9/9/25 at 2:55 p.m. with resident 31 in her room revealed:*She had a refrigerator in her room.*She stated she had not had it for very long, but there is nothing in it that could spoil.*There was no temperature gauge inside the refrigerator or a temperature monitor log to record its temperatures. 2. Observation on 9/9/25 at 8:33 a.m. in resident 29's room revealed his refrigerator did not have a temperature gauge inside it or a temperature monitor log to record its temperatures. 3. Observation on 9/9/25 at 8:44 a.m. in resident 14 and 30's shared room revealed their refrigerators did not have a temperature gauge inside them or a temperature monitor log to record their temperatures. 4. Observation on 9/11/25 at 6:35 p.m. in resident 20 and 13's shared room revealed their refrigerators did not have 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 before2025-09-11 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 certified nursing assistants (CNAs) did not administer a resident's topical (applied to the body) medications and self-administered medications were documented for one of (one) sampled resident (1) who self-administered medications and, at times, requested CNAs to administer her topical medications stored in her room.Findings include:1. Observation and interview on 9/9/25 at 3:35 p.m. in resident 1's room revealed:*The resident had two bottles of eye drops in a plastic container on her bedside table. She reported she administered them herself after naptime.* She had a Tinactin antifungal spay on her nightstand and stated the certified nursing assistants (CNAs) would spray it on her toes every night when they get her ready for bed.*She had Voltaren gel (for joint pain) on her nightstand, and she reported the CNAs applied it a few times a day for her when she asked.*She had antifungal cream, Calmoseptine cream (for…
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 · D2025-09-11 · 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, review the providers dialysis agreement, and policy review, the provider failed to ensure the resident's chosen advance directive (a document that expresses a person's health care wishes if they become unable to speak for themselves) was accurately reflected in the resident's medical record and communicated to the dialysis center for one of one sampled resident (7) who received dialysis services.Findings include:1. Review of resident 7's electronic medical record (EMR) revealed:*He was admitted on [DATE]*His Brief Interview for Mental Status (BIMS) score was 6, which indicated he had severe cognitive impairment.*He had diagnoses of unspecified encephalopathy (disease that alters brain function), end-stage renal disease, dependence on renal dialysis (mechanical cleaning of blood), acute kidney failure with acute cortical necrosis (death of the tissue in the outer part of the kidney), unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities),…
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 before2025-09-11 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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, record review, interview, and policy review, the provider failed to ensure resident care plans had been revised to reflect their current needs for fall prevention for two of two sampled residents (25 and 3) who were identified to have a risk for falling and had fallen.Findings include:1. Observation and interview on 9/10/25 at 8:56 a.m. with resident 25 revealed: *She had been sitting in a recliner at the nurse's station with her walker in front of her. *Her glasses were missing the earpiece on the right side of the frames and were just resting on her nose. *She stated that she could get around well but could not remember if she had fallen recently or what happened to her glasses. Review of resident 25's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had a Brief Interview of Mental Status (BIMS) assessment score of 6, which indicated she had severe cognitive impairment. *She had a diagnosis of dementia (a group of symptoms affecting memory, thinking, and social…
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 before2025-09-11 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 policy review, record review, and interview the provider failed to follow nursing professional standards of practice to ensure nursing staff:*Followed physician orders, and provider's policy for one of two sampled residents (5) with orders for insulin administration and blood sugar level monitoring, and to ensure low blood sugars were reported to the physician per the provider's policy.*Assessed one of one sampled resident (25) for risk of falling, fall prevention interventions had been in place.Findings Include:1. Review of the provider's 6/7/22 Blood Sugar Monitoring policy revealed:*1. Check physicians [physician's] order for blood sugar testing frequency.2. Notify provider if 2 glucose checks are <70 [less than 70] or >400 [greater than 400] in 24 hours and/or change in condition. If no change in condition, notify the PCP [primary care provider] the next day.Hypoglycemia1. If patient is symptomatic, conscious, and able to swallow.2. Administer 6oz of fruit juice, milk, regular soda, or other high…
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 · D2025-09-11 · 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 observation, record review, interview, and policy review, the provider failed to ensure the safety of:*Two of two sampled residents (1 and 4) who used motorized wheelchairs had been assessed for their ability to safely use motorized wheelchairs according to the provider's policy and ensure the safety of other residents.Findings include: 1. Observation and interview on 9/9/25 at 3:35 p.m. with resident 1 in her room revealed: *Certified Nursing Assistants (CNAs) N and O were dressing her and were getting her up in her electric wheelchair. *They used a total-body lift (a mechanical lift and sling used to lift a person's full body) to transfer the resident into her electric wheelchair. *She had been in the hospital recently and was placed on hospice services due to her decline. Review of Resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had diagnoses of anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as…
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 · D2025-09-11 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the provider to maintain the supply of controlled medication (medication at risk for abuse and addiction) according to the provider's policy to ensure:*Oral and injectable lorazepam (controlled anti-anxiety medication) stored in one of one medication storage room had been accounted for with each shift change.*One of one bottle of oral liquid morphine sulfate (pain medication) observed in a drawer at the nurses' station had been stored in a secure area.Findings include: 1. Observation and interview on 9/11/25 at 10:32 a.m. of the medication refrigerator in the medication storage room with registered nurse (RN) G revealed:*A small locked black box which contained one lorazepam oral liquid and one lorazepam injectable for emergency use.*Staff did not count those medications at each shift change.*She was unsure why they had not been counting those medications but agreed that they should have been counted at shift change.*RN G agreed those medications should have had the amount counted like the medications locked in the medication…
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 13 citations
- Potential for harm · Dcited before2025-09-11 · 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 follow infection control practices to ensure:*Two of two sampled residents (29 and 9) oxygen and nebulizer tubing was dated to identify when the tubing had been placed in the residents' room for use according to the provider's process. *One of one sampled resident (1) with an open wound caused by prolonged pressure (pressure ulcer) had been placed on enhanced barrier precautions according to the provider's policy. Findings include: 1. Observation and interview on 9/9/25 at 2:44 p.m. with resident 29 while seated in his recliner in his room revealed:*He was wearing a nasal cannula (flexible tubing with prongs that delivers oxygen through the nose) and received oxygen at a flowrate of two liters via oxygen concentrator.*The nasal cannula tubing had not been dated to indicate when it was put in use. *Resident 29 had a portable oxygen tank attached to his wheelchair which also had an undated nasal cannula attached to it.*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 · Fcited before2024-06-21 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Payroll Based Journal (PBJ) reports, interview, and record review, the provider failed to ensure there was a registered nurse (RN) working for eight consecutive hours per day for 36 days in Federal Fiscal Quarters 1 (October, November, and December 2023) and Quarter 2 (January, February, and March 2024), and one day from June 6th, 2024, through June 14, 2024. Findings include: 1. Review of the provider's Federal Fiscal Quarter 1 (October, November, and December 2023) PBJ Certification and Survey Provider Enhanced Reporting (CASPER) report revealed the following: *There were no eight consecutive hours worked by an RN on the following days: -October 14th, 22nd, and 28th. -November 10th, 11th, 12th, 14th, 24th, 25th, and 26th. -December 3rd, 9th, 10th, 14th, 15th, 17th, 18th, 22nd, 23rd, 24th, 25th, and 31st. Review of the provider's Federal Fiscal Quarter 2 (January, February, and March 2024) PBJ CASPER report revealed the following: *There were no eight consecutive hours worked by an RN on the following days: -January 1st, 6th, 7th, 8th, 13th, 20th, and 27th. -February 1st,…
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 · F2024-06-21 · tag F0848 — widespreadProvide a neutral and fair arbitration process and agree to arbitrator and venue.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, Arbitration Agreement review, and record review, the provider failed to ensure the Arbitration Agreement: *Included the arbitration organizations name and how to contact that organization. *Provided for a location that was convenient for both parties for an arbitration dispute. Findings include: 1. Interview on 6/18/24 at 11:14 a.m. with administrator A revealed the provider had an Arbitration Agreement that was reviewed and requested to be signed by newly admitted residents or their representative. Review of the provider's Arbitration Agreement revealed the following: *Location of Arbitration - The Arbitration will be conducted at a site selected by [provider] which shall be either at [the provider] or somewhere within a reasonable distance of [the provider]. *Time limitation for Arbitration - any request to arbitrate a Dispute must be submitted to [initials of the arbitration agency] (2) years from the date the event giving rising to the dispute occurred. *The agreement provided the initials of the name of the arbitration agency, but did not specify what those…
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 before2024-06-21 · 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
Review of the provider's PBJ CASPER reports revealed the following items triggered: *Federal Fiscal Quarter 1 and Federal Fiscal Quarter 2: -No registered nurse (RN) hours for eight consecutive hours each day for more than four days. -No 24-hour nurse coverage each day for more than four days. -The weekend staffing metric was suppressed, meaning the data submitted was excessively low. Interview on 6/21/24 at 11:30 a.m. with administrator A regarding PBJ reporting revealed: *Minimum Data Set Coordinator(MDS)/registered nurse (RN) C had been responsible to submit the PBJ data to CMS. *The time clock system was not able to automatically upload the payroll data to the PBJ system. -The information had to be entered manually. *Administrator A had recently gained access to the PBJ online reporting site, and the time clock had uploaded the data successfully. *She confirmed the data for Federal Fiscal Year 2024 for Quarter's 1 and 2 had not been submitted accurately. Interview on 6/21/24 at 11:35 a.m. with MDS/RN C regarding PBJ reporting revealed: *She had been responsible to submit PBJ…
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 before2024-06-21 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 review and revise comprehensive care plans to ensure care needs were accurately reflected for six of twelve sampled residents (3, 10, 16, 23, 26, and 37). Findings include: 1. Interview on 6/18/24 at 11:14 a.m. with administrator (ADM) A during the entrance conference revealed there was one resident (16) who received dialysis treatments and one resident who smoked cigarettes (26). Review of resident 16's medical record revealed: *He received dialysis treatments two days a week. *His care plan indicated Fluids as ordered. Restrict or give as ordered. Interview on 6/19/24 at 10:26 a.m. with certified nursing assistant (CNA) R regarding resident 16 and care plans revealed: *If she observed any bleeding at resident 16's dialysis site on his arm, she would report it to the nurse. *He had been on a fluid restriction, and she thought they took it [the fluid restriction] away but she was not sure. -She had seen him have a glass of water in his room, so she had given him water during a routine water…
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 before2024-06-21 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on plan of correction review for survey date 6/21/24, staff member listing, record review and interview, the provider failed to ensure the plan of correction (PoC) review from the 6/21/24 with a completion date of 7/23/24, staff member listing review, record review, and interview, the provider failed to ensure the PoC was followed regarding staff education for the previously cited following citations: F554, F686, F761, and F880. Findings include: 1. Review of the provider's PoC for the above citations revealed education related to F554, F686, F761, and F880 was to be provided to staff with a completion date of 7/23/24. The provider's 7/25/24 staff listing indicated there were a total of 47 staff members. -Of those, 25 were nursing staff members. -An agency registered nurse (RN) was not listed. Review of the provider's documented staff education as stated in the provider's PoC for the above citations revealed: *The provider's PoC for citation F554, Resident Self-Administration of Medications, indicated, All nursing staff are required to complete medication education with post…
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 · E2024-06-21 · 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
A. Based on observation, interview, and policy review, the provider failed to ensure: *As needed (PRN) medications stored in blister pack cards with pharmacist-determined expiration dates had been monitored for expiration and removed for destruction for three of three sampled residents (14, 22, and 31) in one of one medication cart. *Four of four medications had opened or expiration dates indicated, for three of three sampled residents (7, 15, and 33) in one of one medication cart. Findings include: 1. Observation, medication review, and interview on 6/20/24 at 11:38 a.m. with registered nurse (RN) N of one of one medication cart revealed: *PRN blister pack cards (medication cards) with expired medications for three residents (14, 22, and 31): -Resident 14's acetaminophen was dispensed from the pharmacy on 6/10/23 and expired on 6/8/24. -Resident 22's loperamide caplets were dispensed from the pharmacy on 9/14/23 and expired on 4/30/24. -Resident 31's acetaminophen was dispensed from the pharmacy on 4/5/23 and expired on 4/4/24. *Four of four medications had no opened date or…
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 before2024-06-21 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
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 follow acceptable infection control practices during two of two observed dressing changes for two of two sampled residents (4 and 15) by registered nurse (RN) N. Findings include: 1. Observation on 6/20/24 at 11:29 a.m. with registered RN N during a dressing change for resident 15 who was on enhanced barrier precautions (EBP) revealed she: *Put on a gown and a pair of gloves while in the hallway outside resident 15's room and with those gloved hands she: -Picked up a basket of supplies from the shelf in the hall. -Entered the room and turned the light switch on -Moved the resident's personal items off the bedside table. -Placed a paper towel on the bedside table and placed the basket on that paper towel. -Touched the bed control to raise the bed. -Moved blankets to uncover the resident. -Opened the resident's brief to view the pressure area and then closed the brief. -Covered the resident. -Uncovered the resident's foot and removed the resident's sock. -Sprayed wound spray on several pieces of gauze. -Sprayed…
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 before2024-06-21 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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, record review, and policy review the provider failed to ensure two of two sampled residents (8 and 9) had been routinely assessed for safe self-administration of medication. Findings include: 1. Interview and observation on 6/19/24 at 9:03 a.m. with resident 8 revealed: *She was in her bed, eating breakfast. *A bottle of nasal spray was in a small plastic container on her rolling bedside table that had her breakfast tray on it. *Registered nurse (RN) N came into the room, and told resident 8 it was time for her medications. -Resident 8 asked her to leave the medications on her breakfast tray. -RN N stated she was not sure if there was a self-administration physician order, so she was not able to leave them. --She then made sure that resident 8 took the medications. -RN N did not acknowledge the medication in the container or have resident 8 self-administer that medication. Interview on 6/21/24 at 7:57 a.m. with RN N regarding residents who self-administered medications revealed:…
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 · D2024-06-21 · tag F0641 — isolatedEnsure 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, interview, and Centers for Medicaid and Medicare (CMS) Resident Assessment Instrument (RAI) Manual, the provider failed to ensure the Minimum Data Set (MDS) assessments were coded accurately for: *One of one resident (15) who had pressure ulcers. *One of one resident (27) who did not have a catheter. 1. Review of resident 15's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Weekly wound documentation completed on 5/6/24 indicated two grade 2 coccyx pressure wounds. -Resident has two new open sores to coccyx- one on the left and right side. *Her 5/11/2024 Quarterly Minimum Data Set (MDS) assessment, section M (Skin Conditions) indicated the resident had no unhealed pressure ulcers. Interview on 6/20/24 at 2:47 p.m. with MDS/registered nurse (RN) C regarding resident 15's pressure ulcers revealed: *She had completed resident 15's 5/11/24 MDS assessment. *She had not reviewed the weekly wound documentation completed on 5/6/24 before completing the MDS. *She confirmed…
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 · D2024-06-21 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review and policy review the provider failed to ensure one of one sampled resident (16) who required dialysis treatment was monitored for abnormalities upon returning from his dialysis treatment. Findings include: 1. Interview on 6/19/24 at 8:27 a.m. with administrator A revealed resident 16 received dialysis two days per week. Review of resident 16's medical record revealed: *A 12/4/23 physician's order for, Upon return from dialysis: Assess Vital Signs and fistula [a connection between an artery and a vein for dialysis treatment] for bleeding, bruising or other abnormalities prior to resident returning to his room. Document V/S [vital signs] and fistula site. Any abnormal findings or concerns a progress note must be made and faxed to PCP [primary care provider]. *There was no documentation in his treatment administration records that monitoring had occurred for four of sixteen opportunities from April 19, 2024 through June 10, 2024. -Those dates had included 4/19/24, 5/13/24, 5/20/24, and 6/10/24. Interview on 6/20/24 at 10:41 with minimum data set…
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 · D2024-06-21 · 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
Based on observation, interview, record review, and policy review the provider failed to ensure two of two sampled residents (2 and 8) who used bed side rails were appropriately assessed and documentation accurately reflected the type of bed side rail in use. Findings include: 1. Observation and interview on 6/19/24 at 9:03 a.m. with resident 8 revealed: *She was in her bed, eating breakfast. *The side rails on both sides of the upper one-half of her bed were in the up position. *She indicated she had started using the side rails in 2023 to assist her in turning while in bed after she had fractured her her hip. Review of resident 8's medical record revealed: *Her 5/4/24 Brief Interview of Mental Status (BIMS) score was a 15, which indicated her cognition was intact. *An 8/12/20 physician order for OK to use ¼ side rail/grab bar for assist with bed mobility and turning. *A Physical Device Evaluation completed on 4/9/23 included: -Rails on Bed, 1/2 side rail, bilateral (both sides), and Pain medications work well but resident requests side rails to help reposition in bed. *There were…
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 · E2023-05-18 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the provider failed to ensure the proper Medicare notice was provided for three of three sampled residents (7, 13, and 35) following their discharge from part A skilled services. Findings include: 1. Review of resident 7's Medicare Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) revealed: *His last day of covered services was on 4/30/23. *The discharge from part A skilled services was initiated by the provider. *He had covered days remaining and continued to reside in the facility. *He had not received the Notice of Medicare Non-Coverage (NOMNC) form. 2. Review of resident 13's Medicare SNF ABN revealed: *His last day of covered services was on 4/6/23. *The discharge from part A skilled services was initiated by the provider. *He had covered days remaining and continued to reside in the facility. *He had not received the NOMNC form. 3. Review of resident 35's Medicare SNF ABN revealed: *Her last day of covered services was on 4/20/23. *The discharge from part A skilled services was initiated by the provider. *She…
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
$69,512 in federal fines across 2 penalties.
- $63,814 — penalty dated 2024-06-21
- $5,698 — penalty dated 2024-02-06
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.
Part of a chain
This home belongs to LIFESPARK — 4 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.3 | -0.3 vs chain |
| Health inspection | 1 of 5 | 1.0 | ≈ chain avg |
| Staffing | 1 of 5 | 2.5 | -1.5 vs chain |
| Quality measures | 4 of 5 | 3.8 | +0.2 vs chain |
The other 3 homes this chain runs (chain average 1.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| HUBER, DAWN | Individual | W-2 MANAGING EMPLOYEE | since 10/01/2019 |
| STROSCHEIN, CHAD | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2019 |
| CARING PROFESSIONALS INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2019 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner 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.
About 86% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 435114. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-11, 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 →
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