Kadoka Nursing Home
605 Maple St W, Kadoka, SD 57543 · Non profit - Corporation · 31 certified beds · (605) 837-2247 Medicaid only — no Medicare
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- its facility-reported quality-measure 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
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 improved from 1 to 3 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 | 40.8% | 21.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 11.1% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 9.2% | 2.9% | 2.0% | worse |
| 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 | 4.2% | 5.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 33.2% | 19.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.1% | 17.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.6% | 96.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.9% | 4.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 45.0% | 25.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 61.8% | 24.6% | 17.1% | check this† — see note marked dagger below the table |
| Long-stay hospitalizations per 1,000 resident days | 1.82 | 1.52 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.99 | 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.
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.
Therapy staffing: this home’s payroll records show 0.03 therapist hours per resident per day in 2026Q1 — more than 1% 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 31 beds and averages 28.8 residents a day — about 93% occupied, or roughly 2 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 4.25 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.88 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 3.87 hrs/resident/day on weekends vs 4.41 on weekdays — 12% thinner on weekends. RN hours go from 0.92 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% 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.
11 citations, most serious first — scroll within the box to see all.
- Potential for harm · D2026-05-27 · 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 South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, observation, and policy review, the provider failed to review and revise one of one sampled resident's (1) care plan (personalized plan that addresses a resident's care needs, goals, and interventions) after the resident eloped (left the facility without staff knowledge).Findings include:1. Review of the provider's 3/9/26 SD DOH FRI revealed that on 3/8/26 at 2:10 p.m., resident 1 opened the front entrance door of the facility causing the door's alarm to sound. Certified nurse aide (CNA) F responded to the alarm. She saw the front door closing behind resident 1. CNA F redirected the resident back inside the facility and settled her back into her room. At 2:30 p.m. that same afternoon, the door alarm sounded again. CNA G responded to the alarm. He found resident 1 standing in front of the open front door entrance. The resident wanted to go away for a while. She was redirected away from the front…
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 before2025-04-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, and policy review, the provider failed to ensure: *One of one low-temperature dishwasher consistently met the required minimum wash and rinse temperatures for proper sanitation. *Temperature monitoring and documentation was completed consistently for one of one dishwasher temperature logs. Findings included: 1. Observation on 4/14/25 at 12:35 p.m. in the kitchen revealed: *The mechanical dishwashing machine had a label on it that read: -Wash Temperature 120 degrees F [Fahrenheit] minimum. -Rinse Temperature 120 degrees F minimum. *The logs for the dishwasher temperatures for April 2025 were on the counter and included: -Columns to record Wash/Rinse Temp/IN [initials] for each of the three mealtimes listed as Breakfast, Lunch', and Supper. -Each column had only one recorded temperature. -Those temperatures ranged from 111 to 134 degrees F. --Fifteen of those recorded temperatures were not at the minimum wash/rinse temperature of 120 degrees F. *Review of additional dishwasher temperature logs revealed: -For March 2025: - Columns to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · 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
Based on observation, interview, record review, and policy review, the provider failed to adhere to professional standards of care by not ensuring medications were taken by four of four observed residents (3, 9, 14, and 19) at the time those medications had been administered by one of one unlicensed medication aide (UMA) (I) and one of one licensed practical nurse (LPN) (J). Findings include: 1. Observation and interview on 4/14/25 with resident 14 in the dining room revealed: *At 5:30 p.m. a blue, oval-shaped pill, and a round salmon-colored pill were in a medication cup on the dining table in front of the resident. *Resident 14 sat between two female residents at that table. -The table was located near the entrance to the kitchen and around the corner from the medication cart. *At 5:45 p.m. the above medications remained in the medication cup. -Resident 14 stated she wanted to eat something first before she had taken those pills. *At 6:05 p.m. the medication cup was empty. 2. Continued observation in the dining room of resident 9 revealed: *At 5:35 p.m. UMA I placed a powdered…
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 · D2025-04-16 · 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 observation, interview, record review, and facility assessment review, the provider failed to ensure: *One of one sampled resident (20) had been screened for post-traumatic stress disorder (PTSD) upon being admitted to the facility. *The implementation of a trauma informed care program. Findings include: 1. Observation and interview on 4/15/25 at 10:00 a.m. with resident 20 in his room revealed he: *Was a well-groomed, heavy-set man who sat in his wheelchair during the interview. *Was never married, but he had a sister who was involved with his care. *Had lived in the facility for about 18 months. He wanted to live on his own again or in an assisted living facility. *Had a history of health conditions that included heart disease, a stroke that had affected his left side, and a fall that had caused a brain bleed. -Had a new diagnosis of leukemia, but he was not certain what his treatment course was. -Had breathing issues he attributed to the inhalation of jet fumes while he was in the military. *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 · Fcited before2023-12-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and policy review the provider failed to ensure: *One of one kitchen was maintained in a clean and sanitary manner. *Food was stored and labeled safely. Findings include: 1. Observation and interview on 12/18/23 at 10:15 a.m. with dietary manager E while in the kitchen revealed: *A large, thick, white, and brown circle under the dishwasher. *The gas stovetop and burners had dried, burnt food particles on it. *The space between the stovetop and the grill had grease build-up and burnt food particles. *Under the stove and the prep table the floor had a thick build-up of dust, grease and visible chunks of food. *The front of the stove had splattered grease covering the surface. *The stovetop was cleaned weekly every Monday. *The kitchen had been deep cleaned two and a half weeks ago. *The floors were mopped nightly. *The cleaning list was to have been posted on the refrigerator and staff were to place a check mark when completing the task. *She had not kept any logs of past cleaning lists. Observation on 12/18/23 at 4:30 p.m. in the kitchen revealed: *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 · Dcited before2023-12-20 · 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
Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled residents (27) physician's order (PO) for weight monitoring and physician notification of weight changes outside the specified parameters was followed. Findings include: 1. Observation and interview on 12/18/23 at 11:31 a.m. and again on 12/19/23 at 3:00 p.m. with resident 27 revealed he: *Was admitted in August 2023 and his diagnoses included a stroke history, heart disease, diabetes, and a brain bleed. -Was wearing compression socks to help maintain his blood flow and reduce leg swelling. -Weighed less than he had in the recent past. Review of resident 27's electronic medical record (EMR) revealed: *A 9/4/23 PO that included the following instructions: -Weigh the resident daily. -Notify the cardiologist if the resident has a three lb (pound) weight gain overnight or a five lb weight gain in one week. *An 11/28/23 Nutritional Assessment indicated the resident's weight was 288.8 lbs. -That was an increase of 17.2 lbs in 30 days and a 13.8 lb increase since 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.
- Potential for harm · D2023-12-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the Consultant Pharmacist Review reports for 2023, record review, interview, and policy review, the provider failed to ensure a physician's order (PO) included a specific duration of time for an as needed (PRN) psychotropic medication for one of one sampled resident (26) who received a PRN psychotropic medication. Findings include: 1. Review of resident 26's electronic medical record (EMR) revealed: *Two POs for PRN Ativan (psychotropic medication). -One had instructions for administration with seizure activity and the other had instructions for administration with agitation. -The PO for Ativan 0.5 mg every 6 hours PRN for agitation was started on 6/19/23. *Consultant Pharmacist Review 2023 monthly notes completed by pharmacist D that reviewed the resident's EMR for identification of medication irregularities revealed: -Only the PRN PO for Ativan administered with seizure activity had been reviewed. -There was no documentation of the PRN PO for Ativan administered for agitation. *Medication administration records from 6/19/23 through 12/19/23 revealed the PRN…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the provider failed to ensure: *Medications in one of one medication refrigerator were securely stored. *One of one sampled residents (20) had her prescription insulin medication accurately labeled. Findings include: 1. Observation on 12/18/23 at 2:36 p.m. of the medication refrigerator revealed: *It was unlocked on a counter in an alcove near where the north/south and east/west residential hallways intersected. *Inside of the refrigerator was the following: -One syringe of Ativan (psychotropic medication) in a clear plastic container secured by a zip tie. -Multiple stacked boxes of residents' insulin. -A tuberculin vial. *Staff entered and exited that alcove to access residents' paper charts and to use a handwashing sink. Interview on 12/18/23 at 2:54 p.m. with registered nurse (RN) G regarding the medication refrigerator revealed: *It was unsecured. -The key used to lock it had not worked for a few months. -I would have to think someone reported this issue to management. *The medications in the refrigerator were accessible to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-20 · tag F0811 — isolatedEnsure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the provider failed to ensure one of one dietary manager (DM) (E) had completed a State-approved training program for feeding assistants prior to providing two of two observed residents (20 and 26) feeding assistance during one of one observed meal service. Findings include: 1. Entrance conference interview on 12/18/23 at 10:30 a.m. with chief operating officer (COO) A revealed the facility had no paid feeding assistants. Observation and interview on 12/18/23 at 5:07 p.m. with DM E in the dining room revealed: *She sat at one of the dining room tables in between residents 20 and 26. *Resident 20's meal was served on a three-compartment plate. -The consistency of her food was moist-looking and had been modified to a soft texture. *DM E verbally cued and physically assisted the resident to eat her meal. *Resident 26 used a modified spoon to scoop his food and bring it to his mouth to eat. *DM E held a cup to the resident's mouth for him to drink fluids. *She helped feed residents to support her co-workers. *She was not a certified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-20 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the provider failed to ensure an in-room call light system was accessible for one of one sampled resident (13). Findings include: 1. Observation and interview on 12/18/23 at 11:46 a.m. with resident 13 in his room revealed: *He was in bed underneath his bedding wearing a hospital gown. -Individual packets of lip balm and packages of mouth swabs sat on his bedside table. *His television was on, and his call light was lying on top of the bed covers near his feet. -He used his hands to feel on top of his bedding for the call light but was not sure where it was. -He would have tried to get the attention of someone passing by his room if he had needed help. Observation on 12/18/23 at 2:26 p.m. of resident 13 in his room revealed: *He was in bed asleep with the television on. -His call light lay on the floor at the foot of his bed. Interview on 12/18/23 at 2:30 p.m. with certified nurse aide (CNA) I revealed: *Resident 13 was hospitalized about a month ago. -He received end-of-life care and had chosen to remain in bed most of the time.…
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 before2022-12-29 · 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
Based on observation, interview, and policy review, the provider failed to ensure appropriate hand hygiene and glove use to prevent cross-contamination in the handling of ready to eat foods during one of one meal service with one of one cook (E). Findings include: 1. Observation and interview on 12/27/22 from 4:33 p.m. through 5:20 p.m. of the supper meal revealed: *Beginning at 4:33 p.m. with gloves on completed the following food preparation tasks, he: -Used gloved hands obtained a knife from drawer and started cutting a grilled cheese sandwhich. -Placed the grilled cheese sandwhich on plate and with same gloved hands adding crackers and cookies to plate. -Used utensils to serve soup and dish up cauliflower out of a pan and placed on same plate. -Handed the plate to his co-worker. -Looked out to the dining room to see who to serve next as he leaned on countertops and top of the microwave with gloved hands. -Touched drawers to get utensils out, used a pen to write on a sticky note and touched his mask. -Continued to touch the grilled cheese sandwiches, cookies and crackers with 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.
“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
No federal fines in the current CMS record.
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 43A103. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-16, 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.