St William's Care Center

Location & what’s nearby

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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

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.

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.

Met the expected recovery: 71.0% 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 38 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 34% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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.

Staffing

How full it usually is: this home is certified for 60 beds and averages 49.7 residents a day — about 83% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 2.53 hrs/resident/day on weekends vs 3.34 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.54 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 15 most serious are shown; the remaining 10 are one tap away and print in full.

• Actual harm · G2026-02-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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 implement pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) prevention interventions for one of one sampled resident (3) who was identified at risk for developing a pressure ulcer and developed an unstageable (wound bed not visible due to covering, such as debris, dead tissue, scabbing, or a non-removable dressing) pressure ulcer to her left heel while under their care. Findings include:1. Observation on 2/10/26 at 10:57 a.m. of resident 3 in the dining room revealed that she was sitting upright in her wheelchair. She was not wearing heel boots (a cushioned boot used to reduce pressure from a person's heel. 2. Observation on 2/10/26 at 2:21 p.m. of resident 3 in her room revealed she was still sitting in her wheelchair without heel boots on. That had been over approximately three hours she remained in the same position. 3. Review of resident 3's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) revealed a focus area…

  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
• Actual harm · Gcited before2024-10-02 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI] report, interview, record review and policy review the provider failed to prevent staff to resident sexual abuse from occurring for one of one resident (29). Findings include: 1. Review of the SD DOH FRI report for resident 29 revealed: *On 9/21/24 at 11:35 p.m. certified nursing assistants [CNAs] reported to licensed practical nurse (LPN) H that resident 29 was complaining of CNA M being rough after she had used the bathroom and was being cleaned up. *LPN H assessed resident 29 in her room. *Administrator A and director of nursing (DON) B were notified. *Resident 29's power of attorney (POA) was notified. *Resident 29's primary physician was notified. *Administrator A contacted CNA M to suspend her pending investigation results. *Medical director C was contacted and he arranged for her transfer to the local emergency room for further assessment. *CNA M was terminated from the facility on 9/25/24. 2. Interview on 9/30/24 at 4:42 p.m. with resident 29 revealed: *She had a urinary tract infection…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Hcited before2024-07-24 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, record review, and policy review, the provider failed to protect three of five sampled residents (2, 3, and 4) from mistreatment, intimidation, verbal abuse, and physical abuse by one of one certified nurse assistant (J). Findings include: 1. Review of the provider's FRI online report submitted to the SD DOH on 6/30/24 revealed: *Resident 2 was not feeling well on the evening of 6/29/24. She had vomited several times. *Certified nurse assistant (CNA) J was seen by another CNA to have been getting frustrated with resident 2, told resident 2 to shut up, and swatted resident 2's hands away from her incontinence brief. *CNA J was interviewed about the situation and CNA J denied saying shut up to the resident and swatting the resident's hands. *She was assigned educational videos to watch about coping skills, how to calm down in difficult caregiving situations, anger management, and people living with…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-10 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and policy review the provider failed to ensure that two of two sampled residents (27 and 32) had an investigation completed following falls with injuries. Findings include: 1. Observation and interview on 8/7/23 at 4:25 p.m. with resident 27 while he was sitting in his wheelchair revealed: *He had fallen a few times but could not remember when. *He used his wheelchair for mobility. *He had worn glasses and was hard of hearing. Review of resident 27's electronic medical record (EMR) revealed: *On 5/26/23 at 3:30 p.m. he had an unwitnessed fall. *He was able to move all of his extremities. *He had complained of head pain and the loss of vision in his left eye. *Vital signs were taken and documented as follows: -Temperature: 97.3 -Pulse: 50 beats per minute normal is (60-100) -Respirations: 20 per minute -B/P: 119/79 -Oxygen level: 83% on room air normal is (90-100%) --Oxygen had been applied. *Resident was transferred by staff to his bed using the total mechanical lift. *The resident did have a few scratches on his head and one large…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-10 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation, interview, record review, and policy review the provider failed to ensure that two of two sampled residents (27 and 32) who had falls with injuries were reported to the South Dakota (SD) Department of Health after falls with injuries. Finding include: *One of one sampled resident 27 required a transfer to the emergency room for further evaluation and treatment. *One of one sampled resident 32 had sustained injuries to her left leg from improper use of the sit-to-stand mechanical lift. *Refer to F609.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-02-19 · tag F0803 — failed to meet residents' dietary needs — widespread
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interview, and record review, the provider failed to ensure two of two dietary staff (cook L and dietary aide P) followed the menu serving sizes for each diet offered for two of two observed meals. This had the potential to affect all residents who requested the main menu items. Findings Include:1. Observation on 2/10/26 at 11:25 a.m. in the kitchen revealed that cook L was preparing to set up the hot-serving table for the lunchtime meal service. Interview at that time with cook L revealed that most residents requested smaller portions, but she provided about four ounces of the meat option and two ounces of vegetables or two ounces of the side dish to the residents. She did not reference the dietitian approved menu at that time to verify the correct serving sizes for each prescribed resident diet.2. Observation on 2/10/26 from 11:50 a.m. to 12:19 p.m. in the dining room during lunch revealed that cook L was placing serving utensils in the food items. She used a four-ounce scoop for the peas, and two-ounce scoops for the pureed peas, stewed tomatoes, and mashed…

  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 · F2026-02-19 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to:*Minimize cross-contamination via glove use during two of three meals observed by cook L and during food preparation by dietary aide T.*Properly store and sanitize food thermometers prior to use by cook L.*Maintain one of one kitchen in a clean and sanitary manner as evidenced by dusty ceiling vents throughout the kitchen, dusty ventilation fans in one of one walk-in cooler, rusty shelves in one of one walk-in cooler, and food scum buildup inside one of one commercial dishwashing machine.*Monitor and document the temperatures for one of one commercial dishwashing machine according to the provider's policy to ensure it reached the minimum rinse cycle temperature of 180 degrees for sanitization of dishes and equipment used to prepare and serve residents' meals.*Ensure safe food storage practices were maintained as evidenced by storing potentially hazardous foods at room temperature for an extended period of time by one of one…

  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 · F2026-02-19 · tag F0880 — failed to prevent and control infections — widespread
  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 interview, document review, and policy review, the provider failed to ensure a water management program was in place to mitigate the growth and spread of Legionella (a type of bacterium commonly found in natural water sources). This had the potential to affect all residents, staff, and visitors within the facility. Findings include:1. Interview on 2/18/26 at 12:45 p.m. with maintenance director U revealed:*He checked the in-line water heater temperature every morning, and the temperature range was to be no more than 125 Fahrenheit (F), so he kept it at 117-118 degrees F.*They did not add any chemicals to their water for the prevention of Legionella.*The building's water was not tested for chlorine levels.*He or housekeeping sometimes ran the water and flushed the toilets in the empty rooms, but he did not have a formal plan or documentation for running stagnant water. 2. Review of the November 2025 through February 2026 water heater temperatures revealed that the water heater temperatures were always at 117 degrees F. The water temperature was required to be 122 degrees F…

  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 · E2026-02-19 · tag F0658 — failed to meet professional standards of care — pattern
  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

  A. Based on observation and interview the provider failed to ensure one of one sampled resident (32) had anything to eat or drink or had blood glucose monitoring within thirty minutes of receiving Novolog (a fast-acting insulin used to lower blood sugar) administered by licensed practical nurse (LPN) D. Findings include:1. Observation and interview on 2/12/26 at 7:51 a.m. of LPN D revealed: *She woke up resident 32 to administer her insulin. The resident had not eaten breakfast yet but was going to get a room tray. *Resident 32's blood sugar was 264 (normal blood sugars are 70-130), and LPN D administered 5 units of Novolog and 42 units of Toujeo SoloStar (a long-acting insulin). 2. Observation on 2/12/26 at 8:53 a.m. revealed resident 32 was sleeping, her room tray was delivered and left on her bedside table by CNA GG. 3. Interview on 2/12/26 at 9:17 a.m. with resident 32 revealed that the staff did not wake her up when they delivered her room tray, and she did not eat anything yet that day. 4. Observation on 2/12/26 at 9:22 a.m. revealed resident 32 was sleeping, and her breakfast…

  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 · Ecited before2026-02-19 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure medications were securely stored and labeled for safe use according to professional standards to ensure:*One of one medication room was free from expired medical supplies.*Insulin pens for three of six sampled residents (7,12, and 32) were dated when removed from the refrigerator.*Five of five sampled residents (7,9,35,46, and 48) inhalers were dated when opened.*Two of two glucose test strip bottles were dated when opened.*Two of two medication carts were locked when unattended by two of two nurses (B and R). Findings include:1. Observation and interview on [DATE] at 10:20 a.m. in the medication room with licensed practical nurse (LPN)/director of nursing (DON) in training E revealed: *There was a sign that hung on the refrigerator that stored insulin to indicate how long different types of insulins were good for once opened. *There were thirteen swabs that tested for respiratory infections that expired on [DATE]. *There was one…

  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
• Potential for harm · D2026-02-19 · tag F0635 — isolated
  Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure one of one resident (1) had a physician's order for supplemental oxygen when she was readmitted to the facility, and was provided continuous oxygen using a nasal cannula (flexible tubing with prongs that delivers oxygen through the nose) by the staff. Findings include:Based on observation, interview, record review, and policy review, the provider failed to ensure one of one resident (1) had a physician's order for supplemental oxygen when she was readmitted to the facility and was provided continuous oxygen using a nasal cannula (flexible tubing with prongs that delivers oxygen through the nose) by the staff.Findings include: 1. Observation and interview on 2/11/26 at 10:41 a.m. with resident 1 in her room revealed there was an oxygen concentrator (a device that filters room air into purified oxygen). Attached to the concentrator was an NC tube and a plastic bottle that contained water (a bubbler), which was used 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-19 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  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, the provider failed to incorporate one of one sampled resident's (9) Level II (2) Preadmission Screening and Resident Review (PASRR) into the Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment.Findings Include:1. Review of resident 9's electronic medical record (EMR) revealed she had a diagnosis of post-traumatic stress disorder (PTSD) and she was admitted to the facility on [DATE]. Her 11/11/25 MDS comprehensive assessment and 1/28/26 MDS quarterly assessment indicated that a PASRR Level II was not completed.2. Interview on 2/18/26 at 2:30 p.m. with social worker (SW) J revealed that the facility did not have a process to update the staff on if a PASRR Level II was completed for a resident. She completed the PASRR forms and kept them in her office. She did not share the completed PASRR documentation with the interdisciplinary team or registered…

  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 · D2026-02-19 · 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 the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, document review, record review, and policy review, the facility failed to ensure the safety for one of one sampled resident (48) who was identified at risk for elopement (leaving the facility without staff knowledge) and left the building unsupervised on 9/19/25. Findings include:1. Review of the 9/19/25 FRI report submitted to the SD DOH revealed: *On 9/18/25 at 8:47 p.m., resident 48 exited out of the facility's back door. *Another resident's family member heard the alarm and called a staff member who was not on duty and notified her that the alarm was sounding. That staff member called the facility and told the nurse on duty, and she went out and assisted resident 48 back inside. *The wander guard alarm sounded at the door, at the alarm panel, and an alert was sent to the radio staff wore. *Staff did not hear the alarm going off at the panel because no staff was in that area at that time. Not all…

  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 · D2026-02-19 · tag F0868 — isolated
  Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and policy review, the provider failed to ensure medical director EE attended and meaningfully participated in the provider's Quality Assurance and Assessment (QAA) meetings at least quarterly. Findings include:1. Interview on 2/19/26 at 11:25 a.m. with administrator A revealed that the QAA committee meets monthly. She texted medical director EE monthly to remind him of when the meetings were, and he usually texted topics he wished the committee to discuss. He sometimes would attend via telephone. He did not have a nurse practitioner or physician's assistant to attend in his absence. She confirmed she was aware that the medical director was required to attend at least quarterly. 2. Review of the provider's QAA committee binder at that time with administrator A revealed that medical director EE attended the QAA committee meeting via telephone on 1/29/26 (their most recent QAA committee meeting), and he attended in person on 8/13/25. All other months throughout 2025 he either did not attend or only sent a text to administrator A with topics he wanted…

  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 · Ecited before2024-10-02 · 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

  Based on record review and interview the provider failed to ensure appropriate and timely Medicare notices had been provided for two of three sampled residents (47 and 250) who discharged from skilled services. Findings include: 1. Review of resident 47's Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form provided by social services designee E revealed: *Her Medicare Part A Skilled Episode start date was 7/25/24. *Her last covered day of Part A Service was 8/20/24. *Her signed SNF Advance Beneficiary Notice of Non-coverage (ABN) form had been completed on 8/19/24. *She had not been given notice 48 hours prior to her services ending. *Her Notice of Medicare Non-Coverage (NOMNC) form was outdated and did not have the correct header. 2. Review of resident 250's CMS SNF Beneficiary Protection Notification Review form provided by social services designee E revealed: *He was discharged to his home on 6/4/24. *His Medicare Part A Skilled Episode start date was 5/17/24. *His last covered day of Part A Service was…

  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

“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.

Fines & penalties

$132,723 in federal fines across 3 penalties.

• $78,750 — penalty dated 2026-02-19
• $12,048 — penalty dated 2024-10-02
• $41,925 — penalty dated 2024-07-24

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

Who owns this facility

CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

About 93% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in SD