Sanford Chamberlain Care Center
300 S Byron Blvd, Chamberlain, SD 57325 · Non profit - Corporation · 44 certified beds · (605) 234-6518 Medicaid only — no Medicare
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $124,961 in federal fines (most recent 2025-06-12)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (57%) runs well above the national median (45%)
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 | 1 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — 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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 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 held steady at 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 | 23.8% | 21.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.5% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.1% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 5.0% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 6.0% | 5.7% | 6.5% | typical |
| 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 | 2.5% | 5.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 22.7% | 19.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 23.0% | 17.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.5% | 96.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.3% | 4.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.9% | 25.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.2% | 24.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.0% | 1.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.91 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 3.05 | 1.75 | 1.80 | worse |
‡ 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.
Therapy staffing: this home’s payroll records show <0.01 therapist hours per resident per day in 2026Q1 — more than 0% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| 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 — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
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 44 beds and averages 41.4 residents a day — about 94% occupied, or roughly 3 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 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.46 hrs/resident/day on weekends vs 3.79 on weekdays — 9% thinner on weekends. RN hours go from 0.81 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 57% is well above 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 more than at the previous inspection — worsening. 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.
16 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · Jcited before2025-01-09 · 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 South Dakota Department of Health (SD DOH) 1/2/25 facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to: *Ensure there was a plan of action implemented following an incident where one of one sampled resident (1) had become physically aggressive with staff and had struck another resident (2) in the face during the interaction. *Ensure one of one sampled resident (1) who had cognitive impairment was free from psychological and physical abuse by three of three certified nursing assistants (CNA) (G, K, and L) during an episode of the resident having had increased agitation and aggression. *Ensure extended education and training on how to take care of residents with dementia and psychosocial behaviors for all staff had occurred to help them assist one of one sampled resident (1) during episodes of increased agitation and aggression. *Ensure all direct care-givers had knowledge of how to access and review updated care plan changes for the residents.…
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.
- Immediate jeopardy · Jcited before2024-10-31 · 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 South Dakota Department of Health (SD DOH) 9/25/24 facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to: *Ensure the physical and psychosocial wellbeing for one of one sampled resident (1) with a history of trauma expressed feelings of fear, feeling unsafe, and suicidal thoughts that potentially increased after an unwanted entry into her room and an act of physical aggression made towards her by resident (2) who has cognitive impairment. *Ensure two of two sampled residents (2 and 3) were free from acts of verbal and physical aggression towards each other. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on 10/30/24 at 3:06 p.m. to administrator A and executive assistant K for F600 related to resident 1's fears and expressed suicidal thoughts following unwanted encounters with resident 2, lack of necessary interventions to keep resident 2 from entering other rooms and aggressing 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.
- Actual harm · Gcited before2025-06-12 · 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 South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, electronic medical record (EMR) review, video footage review, interview, and policy review, the provider failed to protect the resident's right to be free from physical abuse by: *One of one certified nursing assistant (CNA) (D) who responded to falling incidents with physical force and restraint for one of one sampled resident (1) with cognitive impairment. *Eight additional staff members (E, G, H, I, J, K, L, and M), identified as present at the time the physical abuse occurred, who did not intervene or report those incidents to a supervisor at the time those incidents occurred. Findings include: 1. Review of the provider's 4/7/25 SD DOH FRI revealed: *On 4/7/25, the provider reviewed video footage of resident 1's falls from 4/6/25. *The video footage revealed CNA D assisted [resident 1] roughly back into his wheelchair after he had fallen. *CNA D pushed him [resident 1] up to the desk and locked the brakes on his…
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 · Gcited before2025-06-12 · 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, observation, record review, and interview, the provider failed to implement, review and revise interventions to reduce the risk of falls for two of two sampled residents (1 and 2) with a history of falls and to prevent subsequent falls. Findings Include: 1. Review of the provider's 6/1/25 SD DOH FRI revealed: *[Resident 2] was found on [the] floor at 1910 [7:10 p.m.] by a CNA [certified nursing assistant] .he was attempting to self transfer out of wheelchair by [his room]. *Resident 2 sustained a closed fracture of [his] left hip. *Before the fall, resident 2 was changed from [needing to use] a stand aid [a mechanical device that lifts a resident from a sitting position to a standing position] to a stand pivot with two [staff] assist [assistance]. Interview and review of the 6/1/25 video footage on 6/12/25 at 10:12 a.m. with director of finance N, director of nursing (DON) B, and licensed social worker (LSW) O 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.
- Actual harm · Gcited before2024-12-27 · 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), interview, observation, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (2) who fell, suffered head trauma, and required emergency room treatment, while attempting to sit down on a whirlpool chair when one of one sampled employee (K) failed to ensure the brakes on the whirlpool tub chair were locked. Findings include: 1. Review of the provider's 12/17/24 FRI regarding resident 2 revealed: *She was getting ready to take a bath in the whirlpool tub. *She attempted to sit down on the tub chair. *The tub chair brakes were not locked, and she fell forward landing on her face. -She had supraorbital bruises to both eyes, a skin tear to her right wrist, and she was transferred to the emergency room (ER) for evaluation. Interview and observation on 12/26/24 at 3:05 p.m. with resident 2 revealed: *She stated I look like this is [because] the aide didn't lock brakes on [the] chair.…
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 · G2024-12-27 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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), observation, interview, record review, and policy the provider failed to ensure one of one sampled resident (1) consumed adequate fluid intake to alleviate and prevent dehydration. Findings include: Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review the provider failed to ensure one of one sampled resident (1) consumed adequate fluid intake to prevent dehydration and one of one sampled resident (1) had neurological checks completed after a fall. Findings include: 1. Review of the provider's submitted SD DOH FRI regarding resident 1 revealed: *On 12/8/24 at 1:41 p.m. resident 1 was found on the floor beside his bed. *He stated that he was trying to get up into his wheelchair. *On 12/9/24 resident 1 complained of back pain and staff documented confusion and lethargy (decreased consciousness, fatigue, drowsiness, or sleepiness). *On…
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 · G2024-10-31 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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, and policy review, the provider failed to ensure: *One of three sampled residents (1) had been screened for post-traumatic stress disorder (PTSD) upon admission, quarterly, annually, or upon her return from an inpatient psychiatric hospitalization for suicidal ideations. *Two of three sampled residents (2, and 3) had been screened for post-traumatic stress disorder (PTSD) upon admission, quarterly, or annually. Findings include: 1. Interview on 10/30/24 at 3:07 p.m. with resident 1 revealed: *There was a mental health therapist who came to the facility, weekly, to counsel her. -She had received counseling from that therapist for many years and felt it was very helpful. -She stated, She has dug me out of a hole more than once. *She stated she had been hospitalized for severe depression, PTSD, anxiety and all that stuff. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 8/23/24 Brief Interview for Mental Status (BIMs) assessment score was 15,…
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 · Gcited before2024-07-11 · 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 South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (24) who eloped (left the facility without staff knowledge) and while he was outside of the building, fell and required evaluation at the emergency department. Findings include: 1. Review of the SD DOH FRI revealed: *On 7/10/24 resident 24 had walked out the front double doors of the building without staff knowledge. 2. Observation on 7/11/24 at 11:16 a.m. of resident 24 in his room revealed: *He had small scabbed-over lacerations to the top of his nose, and his upper and lower lip. *He was smiling, laughing, pleasant, cooperative, and conversive with intermittent garbled and nonsensical speech. 3. Interview on 7/11/24 at 11:27 a.m. with registered nurse (RN) J revealed: *RN J had worked as a permanent staff member for five months and had not worked the previous evening when resident 24 eloped.…
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 before2025-08-14 · 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
Number of residents sampled: Number of residents cited: Based on interview, record review and policy review the provider failed to have physician orders for therapeutic leaves, to ensure no disruption in wound cares and scheduled medications supplies for care were available and sent with one of one sampled resident (33) who left the facility for therapeutic leave home visits. Findings include:1. Interview on 8/13/25 at 8:43 a.m. with resident 33 revealed:*He would leave the facility for therapeutic leaves.*He made his own decisions.*He used his wheelchair for mobility. Review of resident 33 electronic medical record (EMR) revealed:*Resident 33 made his own decisions.*There was no physician's order to complete a head-to-toe assessment when he returned from therapeutic leave. *There was no physician's order for his therapeutic leave home visits*His therapeutic leave was not addressed on his care plan. *Resident 33 had the diagnoses of:- Pressure ulcer of sacral region, Shortness of breath, hypertension [high blood pressure], localized edema [swelling], pain, thrombocytopenia [low…
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 before2025-08-14 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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, maintaining sanitary conditions in the kitchenette on [NAME]-wing, and processes to prevent foodborne illnesses for:*One of one cook (H) who had not worn gloves or performed hand hygiene (handwashing) while serving one of one sampled resident's (4) food items to prevent foodborne illnesses. Findings include: 1. Observation on 8/14/25 at 8:15 a.m. with cook H while preparing a meal for resident 4 in the kitchenette of [NAME]-wing revealed he:*Did not wash his hands or put on gloves. With his bare hands, he removed a Ziploc bag of frozen sausage links out of the refrigerator freezer and placed them on a plate.*Touched the panel of the microwave to enter a cook time and put the plate with the sausage links in the microwave.*Took one raw egg, broke it open into a frying pan on the stove top.*Touched the top surface of the plate he placed the food on.*Touched the spatula on the counter.*Touched a dirty…
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 before2025-06-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure care plans were reviewed and revised to reflect the current care needs for two of two sampled residents (1 and 2). Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 3/28/25 Minimum Data Set (MDS) assessment indicated he was rarely understood or able to understand others and was severely cognitively impaired. *His diagnosis included dementia (a group of symptoms affecting memory, thinking and social abilities), psychotic disturbance (a mental state where a person loses touch with reality), mood disturbance (a serious mental illness that causes persistent and intense changes in a person's mood energy and behavior), general anxiety disorder, Alzheimer's Disease, Parkinson's disease (a disorder of the central nervous system that affects movement often including tremors), and conduct…
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 before2024-12-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review the provider failed to ensure one of one sampled resident (1) had neurological checks completed after a fall. Findings include: 1. Review of the provider's submitted SD DOH FRI regarding resident 1 revealed: *On 12/8/24 at 1:41 p.m. resident 1 was found on the floor beside his bed. *He stated that he was trying to get up into his wheelchair. *On 12/9/24 resident 1 complained of back pain and staff documented confusion and lethargy (decreased consciousness, fatigue, drowsiness, or sleepiness). *On 12/9/24 resident 1 was sent to the clinic for an appointment due to the inability to collect a urine sample. -At the clinic appointment he was diagnosed with three rib fractures, a urinary tract infection (UTI), and dehydration. Observation and interview on 12/26/24 at 3:50 p.m. with resident 1 revealed: *He was self-propelling in his wheelchair rapidly. *He fell at least…
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 before2024-10-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review and policy review the provider failed to ensure the care plans were reviewed and revised for four of four sampled residents (1, 2, 3, and 4). Findings include: 1. Review of the provider's 8/13/24 submitted SD DOH FRI regarding resident 4 revealed: *On 8/12/24 at 10:00 a.m. resident 4 slid out of the stand aid lift (a manual lift used to assist from a seated to a standing position) while being transfered to her wheelchair. -Certified nursing assistant (CNA) K assisted resident 4 with the transfer. --No other staff member was present. -The provider reported that CNA K followed resident 4's plan of care by using the stand aid but she had not followed the provider's policy for two staff members being required for transfers with the use of a stand aid. -Resident 4 was not injured from the fall. -The report indicated that one to one education was provided to CNA K immediately after the fall. Interview on…
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 before2024-07-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure necessary food safety guidelines were followed for two of two kitchenettes located in the 100 and 200 hallways which included: *The appropriate storage and labeling of food items. *The cleaning and safe maintenance of kitchen surfaces and appliances. Findings include: 1. Observation on 7/8/24 at 5:32 p.m. of the 200-hallway open-concept kitchenette revealed: *The exterior of the refrigerator had a build-up of dried grayish colored sticky material on and around the door handle. *The interior of the refrigerator contained multiple food items that were opened and not dated or labeled including: -One half-can of vanilla frosting with no opened date. -One partially empty package of blueberry bagels with no opened date. -Two plastic cling-wrapped packages of sliced cheeses with no identifying labels or opened dates. -Two large plastic squeeze bottles of salad dressing substances with no identifying labels or opened dates.…
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 · D2024-07-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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, observation, interview, and policy review, the provider failed to ensure the South Dakota Department of Health (SD DOH) had been notified of two of three incidents of elopement for one of one sampled resident (24). Findings include: 1. Review of resident 24's medical record revealed: *He was admitted on [DATE]. *His diagnoses included dementia with behavioral disturbances and Alzheimer's disease. *His Brief Interview of Mental Status (BIMS) score was a 99, which indicated the interview was not successfully completed. *He had eloped from the facility on 3/1/24, 3/24/24, and 7/10/24. *On 3/1/24 a nurse's progress note indicated: -resident was found outside the [NAME] end door. -Two certified nursing assistants (CNAs) were putting residents to bed and stated they did not see resident leave the building. -[Another resident] was yelling out that the resident [24] had gone out of the North end door on [NAME] household and the door alarm was going off. -Resident was brought into the [NAME] end…
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 before2024-07-11 · 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 observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (24) identified at risk for developing skin injuries and who had acquired a skin injury (wound) received: *Timely skin assessments performed by professional licensed staff. *Timely notification to his physician to obtain orders for treatment. Findings include: 1. Observation and interview on 7/11/24 at 4:20 p.m. with nursing supervisor and wound care nurse (NS/WCN) H regarding resident 24's wound revealed: *He was in his room sitting in his recliner watching television. *When asked to observe his wound he gave his permission and was able to reposition, stand, ambulate and reposition his pants independently. *He had an approximate 1.3 centimeter (cm) length by 0.2 cm width by .02 cm deep open wound with a skin flap near the center left inner buttocks. *The wound was clean, and had no drainage. *NS/WCN H stated the wound had been deeper but was healing from the inside out. *He was prone 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.
“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
$124,961 in federal fines across 4 penalties.
- $43,095 — penalty dated 2025-06-12
- $49,982 — penalty dated 2024-12-27
- $22,465 — penalty dated 2024-10-31
- $9,419 — penalty dated 2024-07-11
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 | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in SD
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. 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 43A073. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-14, 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.