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Lake Andes Senior Living

740 East Lake St, Lake Andes, SD 57356 · For profit - Individual · 43 certified beds · (605) 487-7674 Medicare & Medicaid certified

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Behavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations$102,440 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $102,440 in federal fines (most recent 2024-10-16)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
756 E Lake · (605) 487-7878 · Call to confirm hours
Pharmacy
111 Washington Ave NW · (605) 384-3621 · Call to confirm hours
Grocery
326 W Main St · (605) 487-7241 · Call to confirm hours
Park
38672 291st St · (605) 487-7603 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.7%21.3%15.4%typical
Long-stay residents who lose too much weight2.4%5.6%5.4%better
Long-stay residents with a catheter left in their bladder1.4%2.1%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.9%2.9%2.0%typical
Long-stay residents with depressive symptoms13.3%5.7%6.5%worse
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.2%5.5%3.3%worse
Long-stay residents whose ability to walk worsened12.6%19.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.8%17.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%96.9%95.3%typical
Long-stay residents with pressure ulcers2.7%4.6%4.7%better
Long-stay residents with worsening bladder/bowel control24.6%25.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table20.0%24.6%17.1%worse
Long-stay hospitalizations per 1,000 resident days1.311.521.67better
Long-stay outpatient ER visits per 1,000 resident days1.021.751.80better

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.

11.3%U.S. median 10.7%
Went back to hospital
52.2%U.S. median 56.6%
Met the expected recovery
0.11U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.02hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 52.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 23 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.11 therapist hours per resident per day in 2026Q1 — more than 7% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 5.7–15.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge52.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge39.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge52.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.55
RN hours/ resident / day
0.40
LPN hours/ resident / day
2.20
Aide hours/ resident / day
3.15
Total nurse hours/ resident / day
0.46
RN hoursweekends
38.2%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 43 beds and averages 39.2 residents a day — about 91% occupied, or roughly 4 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 3.15 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.549 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.99 hrs/resident/day on weekends vs 3.22 on weekdays — 7% thinner on weekends. RN hours go from 0.59 to 0.46 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

3
deficiencies at the latest standard inspection (2025-08-21)
17
at the previous standard inspection (2024-09-05)

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.

ABCDEFGHIJKL

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.

21 citations, most serious first. The 13 most serious are shown; the remaining 8 are one tap away and print in full.

  • Immediate jeopardy · K2024-09-05 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the provider failed to ensure care and services according to accepted standards of clinical practice regarding blood sugar monitoring, interventions, and notification to the resident's physician for four of seven diabetic residents (3, 20, 22, and 38) that experienced blood sugar levels outside of the normal range. Interventions and timely follow-up to those blood sugars was not consistently identified in their records. Finding include: Notice: Notice of immediate jeopardy was given verbally and in writing on 9/5/24 at 11:55 a.m. to executive director (ED) A and director of nursing (DON) B of the immediate jeopardy related to F684 when the provider failed to ensure quality of care regarding hypoglycemic (lower than standard blood sugar level range) and hyperglycemic (higher than standard blood sugar level range) risks for diabetic residents. On 9/5/24 at 11:55 a.m. ED A and DON B were asked for an immediate removal plan. Plan: On 9/5/2024, diabetic residents #3, #20, #22, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Kcited before2024-09-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the provider failed to ensure the management COVID-19 cases with 12 of 12 sampled residents (5, 6, 8, 10, 19, 20, 29, 31, 32, 33, 38, and 89) implement appropriate precautions, and prevent further transmission of the disease, including ensuring staff demonstrated the proper use of personal protective equipment (PPE) (e.g. N95 face masks and gowns), and proper hand hygiene between residents to prevent the spread of COVID-19 infection. Findings include: Notice: On 8/27/24: *At 11:30 a.m., immediate jeopardy was identified related to the prevention and control of resident COVID-19 infections at F880. *At 1:25 p.m., notice of immediate jeopardy was provided verbally and in writing to executive director (ED) A, director of nursing (DON) B, and regional nurse consultant (RNC) S. An immediate jeopardy removal plan was requested at that time. The survey team exited the building at 2:00 p.m. Plan: On 8/27/2024, all covid positive residents were moved in…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-10-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the provider's South Dakota Department of Health (SD DOH) facility reported incident (FRI), interviews, observation, and record review, the provider failed to keep one of one resident (1) safe from elopement. Findings include: 1. Review of the provider's SD DOH FRI revealed: *On 10/1/24 at 7:02 p.m., Resident 1 walked to the front door of the facility, pushed on the door, and exited the facility without supervision. *He was wearing a Wanderguard (a wearable device that alarms when individual is within proximity of an alarmed door and/or crosses the threshold of alarmed door). -The Wanderguard functioned appropriately and alarmed when the resident exited the building. *At the time the resident exited the building, all staff were assisting other residents. *CNA G spotted resident 1 across the street at a neighboring house. *CNA G brought the resident back to the facility at 7:07 p.m. *Resident 1 was assessed by licensed practical nurse (LPN) D, the resident was not injured, and his vital signs were within normal limits. *Resident 1's daughter was notified, as well…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-21 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 record review, the provider failed to ensure kitchen equipment surfaces were clean and food was stored under clean and sanitary conditions in one of one freezer.Findings include: 1. Observation on 8/18/25 at 4:45 in the kitchen revealed the top of the dishwasher had a buildup of an unidentified substance such as dirt, dust, or dried cleaning chemicals. 2. Observation on 8/18/25 at 4:50 p.m. in the kitchen revealed:*The freezer had dirt particles and unidentified spilled material covering a large portion of the bottom.*Single serving ice cream cups were stored on the same shelf as frozen bacon.*Dirt build-up around appliances and preparation tables on the floor.-Tables and appliances had not been moved to clean around and under them. 3. Observations were made on 8/19/25 at 8:30 a.m., 8/20/25 at 10:40 a.m., and the morning of 8/21/25 at 10:00 a.m. of the top of the dishwasher and the surface had not been cleaned and remained in the same condition as 8/18/25. 4. Interview on 8/21/25 at 10:05 a.m. with dietary aide I revealed:*She had been employed…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 record review, interview, and policy review, provider failed to ensure smoking evaluations were completed quarterly for one of seven sampled resident (12) who continued to smoke at the facility. Findings include:1.Review of resident 12's electronic medical record (EMR) revealed:*She was admitted on [DATE].*She had a primary diagnosis of Alzheimer's dementia.*Her Brief Interview for Mental Status (BIMS) assessment score on 7/17/25 was 7 indicating she had severely impaired cognition.*Her current care plan had a focus area of smoking cigarettes and is at risk for injury related to smoking initiated on 2/1/24.*Interventions in place were:-Assist outside and ensure clothing is appropriate for weather.-At times is not compliant with order to smoke only three cigarettes a day.-Complete smoking evaluation on admission, quarterly, and prn (as needed) to determine if resident 12 able to smoke independently or requires staff assistance.-Ensure resident 12 is aware/compliant with facility smoking policy.-Keep…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the provider failed to ensure infection control practices were followed by allowing one of one sampled resident's (5) oxygen tubing to sit on the floor.Findings include:1. Observation on 8/19/25 at 9:13 a.m. revealed resident 5's nasal cannula [the part of oxygen tubing that touches the resident's face] was on the floor while she was in bed watching TV.2. Observation on 8/19/25 at 9:50 a.m. revealed resident 5 was no longer in her room, her nasal cannula was still on the floor.3. Observation and interview on 8/20/25 at 9:45 a.m. revealed resident 5's nasal cannula was lying on the floor.*Resident 5 reported that sometimes staff roll up her oxygen tubing/nasal cannula and place it on the machine, sometimes they allowed it to be on the floor.*She said the oxygen tubing was not replaced when it is found on the floor.*The oxygen tubing was dated 8/13/25. 4. Interview on 8/21/25 at 10:30 a.m. with ADON B revealed:*When not in use, oxygen tubing should be rolled up and hung on the oxygen machine for storage.*It should never be on the floor.*If nasal…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-05 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the provider failed to ensure a clean and homelike environment was maintained for all 39 residents who resided at the facility. Findings include: 1. Observation on 8/27/24 at 12:10 p.m. revealed: *The heat register outside of resident room [ROOM NUMBER] was rusted and not cleanable. *The storage cove outside room [ROOM NUMBER] contained: -An oxygen concentrator. -An locked out Volaro lift. -A rolling desk chair. -A shelf contained: --Eight individual incontinent undergarments. --An open package of bathroom hygiene wipes. --An open package of incontinent undergarments. --A sheepskin blanket/bed pad. --A sign that indicated enhanced barrier precautions. Observation on 9/3/24 at 9:00 a.m. of the east hallway revealed there was a cloth chair that had a stain on the seat. Observation on 9/3/24 at 9:47 a.m. of the dining room revealed: *The west side Fujitsu air conditioning unit had 21 brown drip stains on it. *The east side Fujitsu air conditioning unit had four…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-05 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview, staff schedule review, and payroll record review, the provider failed to ensure a registered nurse (RN) was scheduled for eight consecutive hours for two of four weekends in May 2023. Findings include: 1. Interview on 9/4/24 at 3:03 p.m. with executive director A regarding the required eight hours of RN coverage on a daily basis revealed he: *Was responsible for filing the payroll-based journal (PBJ) reports. -He began submitting the facility's payroll-based journal information starting with Quarter 3 of 2024. *Had been aware they did not have an RN working in the facility on 5/7/24, 5/27/24, and 5/28/24. *Stated they always had a nurse in the building, but not always an RN on weekends. 2. Review of the provider's staff schedule and payroll record for May 2023 revealed they did not have RN coverage on the following dates: *Sunday 5/7/24. *Saturday 5/27/24. *Sunday 5/28/24.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-09-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 food items for resident consumption were appropriately labeled and stored in a safe and sanitary manner for the following: *Three of five freezers that contained food items that were not labeled or dated. *One of one resident refrigerator that contained food items that were not labeled, dated, or discarded by the use-by date. 1. Observation on 8/27/24 at 8:15 a.m. of the lower-level food storage area revealed: *A freezer labeled Freezer 1 contained two bags of fruit that were opened and not labeled or dated. *A freezer labeled Freezer 2 contained: -One bag of waffles that was open and not dated. -One bag of French Toast that was opened and not dated. -Three bags of frozen omelets that were not labeled or dated. -Garlic bread that was open and not dated. *An unlabeled freezer contained two bags of frozen vegetables that were open and not labeled or dated. 2. Observation on 8/27/24 at 10:49 a.m. of the resident refrigerator located in the therapy room revealed: *What appeared to be fruit in a plastic…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-05 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, policy review, and job description review the provider failed to ensure the facility was operated and administered by executive director (ED) A and director of nursing (DON) B, in a manner that ensured the safety and overall well-being of all 39 residents in the facility. Those areas included: *Maintaining an effective infection control program that included following appropriate infection control procedures for the prevention and management of COVID-19 infections which included: -The implementation of appropriate precautions, including enhanced barrier precautions. -Ensuring staff demonstrated the proper use of personal protective equipment. -Hand hygiene after caring for infected residents. *Ensuring quality of care regarding hypoglycemic and hyperglycemic risks for four of seven insulin-dependent diabetic residents (3, 20, 22, and 38) which included interventions and physician notification according to blood glucose parameters set by the resident's physician. *Ensuring the facility was safe, clean, comfortable, and had a homelike…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-05 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and policy review, the provider failed to implement an effective quality assurance process improvement (QAPI) program that focused on identifying and improving systemic problems. Findings include: 1. Interview on 9/5/24 at 4:44 p.m. with executive director (ED) A revealed: *Regarding their QAPI Program: -The committee met monthly with the medical director in attendance. -They had developed a performance improvement plan (PIP) for falls which included reviewing interventions that were put in place. *Regarding their infection prevention & control program and their 5/6/24 COVID-19 Outbreak policy: -He agreed that they were currently experiencing a COVID-19 outbreak in the facility. -He was aware that they had allowed residents with confirmed COVID-19 infection to share a room with residents that did not have that respiratory pathogen, increasing the likelihood of the transmission of COVID-19 infections. -He thought they were doing what was best for the residents by allowing the residents who were not infected to remain in the room with a resident with confirmed…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-05 · tag F0944 — widespread
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on employee file review the provider failed to ensure that seven of seven sampled employees (B, C, J, P, Q, X, and Y) had been educated on the quality assurance and performance improvement process of the facility. Findings include: 1. Review of employee B, C, J, P, Q, X, and Y's files revealed there was no documentation they had not received the mandatory quality assurance and performance improvement education per the regulation for an extended survey. .

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-05 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 dignity was maintained for two of three sampled residents (19 and 34) who had urinary catheter drainage bags that were not covered. Findings include: 1. Observation on 8/27/24 at 11:51 a.m. with resident 34 revealed: *He was in his wheelchair in the dining room with his urinary catheter drainage bag hanging under the wheelchair. *The urinary catheter drainage bag was not covered and contained visible urine. Observation on 8/29/24 at 8:43 a.m. with resident 34 revealed: *He was in the living room near the television with his urinary catheter drainage bag hanging under his wheelchair. *The urinary catheter drainage bag was not covered and contained visible urine. 2. Observation on 9/3/24 at 2:55 p.m. with resident 19 revealed: *He was in bed with a urinary catheter drainage bag hanging from the bed bar on the left side of his bed. *The urinary catheter drainage bag was not covered and half-filled with visible urine. *The urinary catheter drainage bag was visible from the hallway. 3. Interview on 9/03/24…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · E2024-09-05 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the provider failed to ensure the proper Medicare notices were completed and provided timely for three of three sampled residents (12, 38, and 39) prior to their discharge from Medicare Part A skilled services. Findings include: 1. Review of the Entrance Conference Worksheet completed by the provider on 8/27/24 revealed six residents were listed who had been discharged from Medicare Part A skilled services: *Five of those residents remained in the facility following their discharge from Medicare Part A. *One of those residents (39) was identified on the worksheet above as being discharged to home following his discharge from Medicare Part A. 2. Review of resident 39's CMS (Centers for Medicare and Medicaid Services) SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form completed by business office manager (BOM) U on 8/29/24 revealed: *Resident 39's Medicare Part A Skilled Services Episode start date was 3/18/24. *His last covered day on Medicare Part…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-05 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    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 ensure privacy had been maintained for four of four sampled residents (35, 36, 38, and 139) who had adjoining rooms with a shared bathroom. Findings include: 1. Observation and interview on 8/27/24 at 12:28 p.m. with resident 35 revealed: *Resident 35 resided in room [ROOM NUMBER] which shared a bathroom with room [ROOM NUMBER]. *Both of those rooms' bathroom doors had been removed. *A shower curtain was hung in place of the door on resident 35's side of the room. *There was no curtain on the side of the bathroom shared with room [ROOM NUMBER]. *room [ROOM NUMBER] was being used to store resident equipment including a recliner, a bed, cardboard boxes, and linens. -Staff entered room [ROOM NUMBER] to access these items. *Resident 35 stated that she could not close the door because there was no door to close. 2. Observation on 8/27/24 at 1:34 p.m. and throughout that day with resident 36 in room [ROOM NUMBER] revealed: *The bathroom doors of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-05 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the provider failed to ensure the care plans for two of two sampled residents (19 and 139) reflected their current needs: *Resident 139's care plan did not include fall and elopement interventions. *Resident 19's care plan did not include enhanced barrier precautions (EBP) (use of gown and gloves while providing contact care) due to his open wounds and his indwelling catheter. Findings include: 1. Observation on 8/27/24 at 8:52 a.m. of resident 139 while she was lying in her bed revealed: *Her bed had been in a lowered position. *A fall mat was on the floor next to the bed. Review of resident 139's electronic medical record (EMR) revealed: *She had been admitted on [DATE]. *On 8/29/24 she had been identified as a fall risk. *On 8/29/24 she had been identified as an elopement risk. -An order had been obtained for a Wanderguard (a door alarming bracelet). Review of resident 139's current care plan revealed: *There had not been any indication for 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-05 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the provider failed to ensure care plans were revised to reflect the current care needs of two of two sampled residents (22 and 38) related to: *Resident 22 who had a central venous catheter (CVC) he used for dialysis treatments. *Resident 38 who checked her blood sugars and self-administered insulin. Findings include: 1. Observation on 8/29/24 at 12:46 p.m. of resident 22 while seated in his wheelchair revealed he had a central venous catheter (CVC) he used for dialysis treatments. Review of resident 22's care plan revealed: *I have End Stage Renal disease and require dialysis. *I go to dialysis on Monday, Wednesday & Friday @ 1000, make sure I have had my meal and medications before I go, I take a sack lunch to dialysis. *Monitor Bruit and thrill, redness or swelling at site every shift. Nursing. *Notify my MD of any shunt problems: no bruit, bleeding, port problems, symptoms of infection, abnormal labs, persistent symptoms of fluid retention…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-05 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and policy review the provider failed to ensure complete and accurate documentation had been entered in the resident records for four of twenty (20, 22, 34, and 38) sampled residents. Findings include: 1. Review of resident 20's electronic medical record (EMR) revealed: *The physician was to be notified for blood sugars greater than 401. *A blood sugar reading above 401 was documented 8/5/24. -There was no documentation to indicate that the physician had not been notified. 2. Review of resident 22's EMR revealed: *The physician was to be notified for blood sugars greater than 351. *Five blood sugar readings above 351 were documented between 7/27/24 and 8/28/24. -There was no documentation to indicate that the physician had not been notified. 3. Review of resident 34's EMR revealed: *A 9/5/24 progress note stated Held care conference for [resident 20's name] today but no answer from poa [power of attorney]. Resident will remain a DNR/DNI [do not resuscitate/do not intubate] Code status and be here for long term care. -Resident 34's EMR contained…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and interview, the provider failed to ensure one of one sampled resident (11) had documentation of a power of attorney for healthcare that would have allowed information to be released to the resident's friend. Findings include: 1. Review of resident 11's electronic medical record (EMR) revealed: *He had a brief interview for mental status (BIMS) score of 7 which indicated he had severe cognitive impairment. *He had a friend listed as a contact for care conferences and his emergency contact. *On 9/13/23 resident 11's friend had given verbal consent for him to receive an Influenza and a Respiratory syncytial virus (RSV) vaccination. *On 4/30/24 verbal education had been given to resident 11's friend regarding the increase in his Mirtazapine (an antidepressant) from 7.5 milligrams (mg) to 15 mg once daily at bedtime. -Resident 11's friend had verbalized understanding and had been ok with the increase. *On 5/14/24 at a care conference, resident 11's code status had been reviewed. Resident 11's friend was on board if hospice services had been required. Interview…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 record review, interview, observation and policy review, the provider failed to ensure: *One of one sampled resident (11) had been re-weighed after a nine-pound weight loss within 13 days. *One of one sampled resident (38) had been accurately assessed for self-administration of medication. Findings include: 1. Review of resident 11's electronic medical record (EMR) revealed: *On 8/8/24 a weight of 165 pounds had been documented. *On 8/21/24 a weight of 156 pounds had been documented. *There was no documentation found that resident 11 had been reweighed due to that 5.45% weight loss in 13 days. Interview on 9/3/24 at 3:19 p.m. with certified nursing assistant (CNA) N regarding a change in a resident's weight revealed: *She would have informed her charge nurse of the weight change and then she would reweigh the resident. Interview on 9/4/24 at 3:26 p.m. with regional nurse consultant S, director of nursing B, and assistant director of nursing C regarding re-weighing residents revealed: *They had some…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 record review, interview, and policy review the provider had failed to ensure one of one sampled resident (139) had as needed (PRN) lorazepam (antianxiety medication) order renewed for use beyond 14 days. Findings include: 1. Review of resident 139's electronic medical record (EMR) revealed: *On 8/15/24 an order for lorazepam 0.5 milligrams (mg) orally to be given every six hours as needed for anxiety. *On 8/18/24 an order for lorazepam 2 mg per milliliter (ml) to be given 0.5 mg every six hours as needed for anxiety. *On 8/20/24 an order for lorazepam 0.5 mg to be given 0.25 mg every 12 hours as need for anxiety. *All orders had been active until 9/4/24. 2. Interview on 9/4/24 at 3:34 p.m. with regional nurse consultant S, director of nursing B, and assistant director of nursing C regarding resident 139's prn lorazepam revealed: *They had not been aware that all three lorazepam orders had not been renewed. *They all had agreed that the three as needed orders for lorazepam were not current. *They obtained a new order on 9/4/24 for resident 139 for lorazepam 2 mg/ml give…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$102,440 in federal fines across 2 penalties.

  • $10,839 — penalty dated 2024-10-16
  • $91,601 — penalty dated 2024-09-05

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ACCURA HEALTHCARE — 41 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.5-1.5 vs chain
Health inspection 1 of 52.6-1.6 vs chain
Staffing 3 of 53.1-0.1 vs chain
Quality measures 4 of 52.8+1.2 vs chain
The other 40 homes this chain runs (chain average 2.5★, per CMS)
1 of 5Aberdeen Health And RehabAberdeen, SD 1 of 5Accura HealthCare of TekamahTekamah, NE 1 of 5Accura Healthcare of CarrollCarroll, IA 1 of 5Accura Healthcare of MarshalltownMarshalltown, IA 1 of 5Accura Healthcare of Newton East, LLCNewton, IA 1 of 5Accura Healthcare of O'NeillO' Neill, NE 1 of 5Accura Healthcare of Pleasantville, LLCPleasantville, IA 1 of 5Accura Healthcare of ShenandoahShenandoah, IA 1 of 5Green Lea Senior LivingMabel, MN 1 of 5Shell Rock Senior LivingShell Rock, IA 2 of 5Accura Healthcare of Cascade LLCCascade, IA 2 of 5Accura Healthcare of CrestonCreston, IA 2 of 5Accura Healthcare of FranklinFranklin, NE 2 of 5Accura Healthcare of Knoxville, LLCKnoxville, IA 2 of 5Accura Healthcare of Lake City, LLCLake City, IA 2 of 5Accura Healthcare of MuscatineMuscatine, IA 2 of 5Accura Healthcare of OnawaOnawa, IA 2 of 5Accura Healthcare of Spirit LakeSpirit Lake, IA 2 of 5Sterling Park Health Care CenterWaite Park, MN 2 of 5Woodlyn Heights Healthcare CenterInver Grove Heights, MN 3 of 5Accura Healthcare of Ames, LLCAmes, IA 3 of 5Accura Healthcare of Aurelia, LLCAurelia, IA 3 of 5Accura Healthcare of Cherokee, LLCCherokee, IA 3 of 5Accura Healthcare of FullertonFullerton, NE 3 of 5Accura Healthcare of Pomeroy, LLCPomeroy, IA 3 of 5Accura Healthcare of StantonStanton, IA 3 of 5Accura Healthcare of ToledoToledo, IA 3 of 5Meadow ManorGrand Meadow, MN 3 of 5Prairie View Senior LivingTracy, MN 3 of 5Traditions Memory Care of NewtonNewton, IA 4 of 5Accura HealthCare of North PlatteNorth Platte, NE 4 of 5Accura Healthcare of Le MarsLe Mars, IA 4 of 5Accura Healthcare of MilfordMilford, IA 4 of 5Accura Healthcare of New HamptonNew Hampton, IA 4 of 5Accura Healthcare of Ogden, LLCOgden, IA 4 of 5Accura Healthcare of Sioux City, LLCSioux City, IA 4 of 5Faulkton Senior LivingFaulkton, SD 5 of 5Accura HealthCare of HartingtonHartington, NE 5 of 5Accura Healthcare of BancroftBancroft, IA 5 of 5Karlstad Healthcare Center INCKarlstad, MN

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
TEALWOOD ENTERPRISE INCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2012
GROFF, HOWARDIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER50%since 09/03/2008
SHERIDAN, GAILIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER50%since 08/29/2008
BERNDT, PAULIndividualW-2 MANAGING EMPLOYEEsince 03/13/2024
WRIGHT, MOLLYIndividualW-2 MANAGING EMPLOYEEsince 01/01/2023
LENEAVE, TEDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 10/01/2019
AMERICAN HEALTHCARE MANAGEMENT SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2019

CMS files one row per role, so the 10 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$3.7M
Net patient revenuemost recent cost report
+8.5%
Operating marginrevenue minus expenses
$187K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 54%Medicare 6%Other / private 40%

This home reported $187K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$231per resident / day
operating cost
$7,032per month
≈ monthly operating cost
$253per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in SD

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the South Dakota Medicaid page.

Typical monthly cost in South Dakota
$9,444/mo
Nursing home (semi-private)
$10,190/mo
Nursing home (private)
$4,900/mo
Assisted living

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 435097. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-21, 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.

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