Flandreau Santee Sioux Tribe Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to follow food safety standards by not having monitored and documented food temperatures for 40 of 192 meals served to residents from 5/1/25 through 8/3/25. Findings include:1. Observation and interview on 8/5/25 at 10:15 a.m. with cook E in the kitchen revealed:*A three-ring binder on top of the steam table labeled dinner temp book.*Cook E stated kitchen staff were to document food temperatures in the temp book.*He stated there was a temp book for breakfast, dinner, and supper.*He knew food had to be heated to certain temperatures.*He agreed there were some food temperatures that were not documented in the dinner temp book. Review of the breakfast, dinner, and supper food temperature books from 5/1/25 through 8/3/25 revealed 40 of 192 meals served to residents did not have documentation to support the temperatures of the foods served to the residents had been checked for safety before being served. Interview on 8/6/25 at…

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

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 safety of one of one sampled resident (14) identified at risk for elopement, who had eloped (left the facility without staff knowledge). Failure of staff to ensure adequate supervision put him at risk for physical injury or serious harm. This citation is considered past non-compliance based on the corrective actions the provider implemented immediately following the incident.Findings include:1. Review of the SD DOH FRI regarding resident 14 revealed:*On 7/9/25 at approximately 5:10 p.m., resident 14 had been seen on the unit by one nurse and two certified nursing assistants (CNAs).*At approximately 5:12 p.m., the front door wander guard alert system alarm sounded.*At 5:19 p.m., CNA F responded to the alarm at the front door, checked the front of the building and the front parking lot. Having not seen anyone, she returned to the facility, shut off 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.

Based on observation and interview, the provider failed to ensure two of two medication carts had not contained expired medications that were available for administration to residents.Findings include:1. Observation on 8/7/25 at 10:11 a.m. of the medication cart on the green wing revealed it contained: *Fifty tablets of Tylenol 325 milligrams (mg) that had expired in June 2025.*Twenty-five tablets of Carbidopa/Levodopa (medication to help treat Parkinson's disease symptoms) 25/100 mg that had expired in June 2025*Twenty-nine tablets of Diphenhydramine (allergy medication) 25 mg that had expired in July 2025. 2. Observation and interview with registered nurse (RN) H immediately following the above observation of expired medications in the med carts revealed she:*Agreed that the above medications had expired.*Stated the night nursing staff should have been checking the medication carts for expired medication and removed for potential administration to residents. 3. Observation on 8/7/25 at 10:25 a.m. of the medication cart on the blue wing revealed twenty tablets of Gabapentin…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure care plans reflected the current individualized activities of daily living (ADL) and pressure ulcer prevention and treatment needs of two of two sampled residents (1 and 2). Findings include: 1. Observation on 8/6/24 at 1:04 p.m. of resident 2's room revealed her bed had an air mattress and positioning cushions on it. Observation and interview on 8/6/24 at 2:12 p.m. with resident 2 while in her room revealed she: *Was seated in a specialized wheelchair. Her legs were elevated and rested on pillows. *Stated she repositioned herself in bed frequently and could achieve several different positions while in her wheelchair. *Stated the staff used the air mattress and the positioning cushions for pressure relief when she was in bed. *Relied on staff for assistance with most of her care needs. *Had a pressure sore (ulcer) for at least two years and felt they are doing a good job of healing it. Review of resident 2's medical…

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.

Based on observation, interview, and policy review, the provider failed to ensure three of three kitchen staff (H, K, and L) had: *Practiced appropriate hand hygiene and glove use during two of two meal preparations. *Performed proper sanitation of the food thermometer while temping the food items before serving the residents. Findings include: 1. Observation on 4/3/24 at 8:17 a.m. in the main kitchen with cook H revealed he: *Used a cloth to remove a hot pan of bacon from the oven. *Checked the temperature of the bacon with a thermometer, used that same cloth to wipe off the thermometer, and sat the thermometer on the counter. *Used that same cloth to remove several other food items from the oven. *Continued to use that same uncleaned thermometer and wiped it off with that same cloth while he checked the temperatures of the eggs and oatmeal. 2. Continued observation on 4/3/24 at 8:25 a.m. in the main kitchen with cook H revealed: *He had on a pair of single-use gloves. *While wearing those gloves he opened the refrigerator removed a container of sausage and placed the sausage 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, electronic medical record review, interview, and policy review, the provider failed to ensure one of one sampled resident (11) with a diagnosis of quadriplegia had an accurate assessment that included a physician acknowledgment order for the use of a seatbelt and wrist splints. Findings include: 1. Observation on 4/2/24 at 3:05 p.m. with resident 11 revealed he was: *Sitting in a motorized wheelchair with a locked seatbelt across his lap helping keep him in an upright position in the chair. *Not wearing wrist splints. 2. Review of resident 11's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His diagnoses included quadriplegia. *There was no physician's order for the seatbelt. *There was a physician's order for the wrist splints. *No assessments for the use of the seatbelt or the wrist splints. *The 2/1/24 care plan did not include the use of the seatbelt or the wrist splints. 3. Interview on 4/4/24 at 1:42 p.m. with director of nursing (DON) B regarding restraint use…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, closed record review, and policy review, the provider failed to: *Ensure, when made aware a resident (103) was going to a dental appointment that had not previously been disclosed to the facility, appropriate communication paperwork was sent to the dentist as well as subsequent notification to the physician about the resident's condition on return and the nurse's determination to hold a blood thinning medication, and accurate oral/dental assessment was documented for the admission assessment. *Ensure, when made aware a resident (104) planned not to return from a therapeutic leave, the resident had received any necessary discharge instructions and had appropriate disposition of medications documented. Findings include: 1. Observation and interview on 4/3/23 at 2:02 p.m. with resident 103 revealed: *One tooth was present in the middle of her bottom jaw, and no teeth were visible on the top jaw. *She reported her gums are very sore from all my teeth getting pulled 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.