Scotchman Living Center
503 West Pine, Philip, SD 57567 · Non profit - Corporation · 42 certified beds · (605) 859-2583 Medicaid only — no Medicare
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- inspectors recorded 3 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- the CMS record shows $47,655 in federal fines (most recent 2025-01-27)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (58%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 35.3% | 21.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.4% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.7% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 7.8% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 16.5% | 5.7% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 7.0% | 5.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 29.4% | 19.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 7.0% | 17.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 18.2% | 4.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 30.8% | 25.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 40.2% | 24.6% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.01 | 1.52 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.23 | 1.75 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.06 therapist hours per resident per day in 2026Q1 — more than 3% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 42 beds and averages 32.5 residents a day — about 77% 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 5.07 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.08 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.48 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.17 hrs/resident/day on weekends vs 5.44 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.24 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
13 citations, most serious first — scroll within the box to see all.
- Actual harm · Gcited before2025-01-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell, suffered head trauma, and required emergency room (ER) treatment when one of one certified nursing assistant (CNA) (B) failed to use a gait belt as directed in the resident's care plan while assisting the resident to the bathroom. Failure to use the gait belt potentially contributed to resident 1's fall which resulted in an injury that required treatment at the ER. This citation is considered past non-compliance based on review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's 1/10/25 SD DOH FRI regarding resident 1 revealed: *She was walking with her walker and certified nursing assistant (CNA) B to get dressed for the day. *She did not have a gait belt on. *She fell backward and hit her head on her end table, which caused a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-12-19 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and document review, the provider failed to protect one of one sampled resident's (4) right to be free from neglect by one of one certified nursing assistant (CNA) N who had not followed the resident's care plan related to transferring (moving from one place to another) which resulted in an open wound on her leg. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Interview on 12/17/24 at 3:42 p.m. with resident 4 revealed: *She was talking about her recent dermatology appointment. *When asked if she had any sores or wounds, she pulled up her left pant leg. *She said she got that wound on her leg over a year ago. *She explained that CNA N helped her into bed and her left leg got caught on something. -She got a skin tear from that accident. -CNA N transferred her using the pivot technique rather than with the full-body mechanical lift. -She said that [CNA N] was in a hurry. *She did not blame the CNA for the accident and was very…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-12-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the provider failed to adequately treat pressure injuries for one of one sampled resident (11) by not following wound care nurse recommendations, and not notifying the resident's physician, resulting in a non-healing pressure injury. Findings include: 1. Review of resident 11's electronic medical record (EMR) revealed: *He had decreased feeling in his lower legs due to paraplegia (the inability to voluntarily move the lower extremities) from a previous spinal cord injury. *He also had diagnoses of congestive heart failure and dementia. *He had a pressure related injury to his left lateral ankle diagnosed on [DATE]. *His wound care was being managed by wound care registered nurse (RN) G. *RN G assessed his wound once weekly and placed orders for how to care for the pressure injury. 2. Review of resident 11's care plan revealed: *The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] paraplegia.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-03-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the South Dakota Department of Health (SD DOH) complaint online report, interview, and policy review, the provider failed to protect one of one sampled resident (20) from mistreatment while receiving care from staff. Findings include: 1. Review of the SD DOH complaint online report revealed the following: *On 2/8/24 at 12:30 p.m. certified nursing assistant (CNA) C reported to registered nurse (RN) B that while providing care in the morning for resident 20, resident 20 had grabbed the back of CNA D's arm and twisted it. -That caused three open abrasions and redness on CNA D's arm. -CNA D had put resident 20's hands between her legs and put her weight on top of resident 20. -Resident 20 began yelling, You're going to break my arm. -CNA D stated, You're going to get dressed, and you're not going to hit me anymore. -CNA C told CNA D to ease up [on resident 20], and called out for help from other staff members. -CNA E came into the room and saw that CNA D to be straddling on top of resident 20…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-20 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, American Society of Consultant Pharmacist Medications (ASCP) resource review, and policy review, the provider failed to ensure:*An extended-release medication was not crushed by one of one observed registered nurse (RN) (C) who then administered that medication to one of one sampled resident (31).*A laxative documented as administered to one of one sampled resident (31) by one of one observed RN (C) who did not observe that medication was taken. Those findings resulted in a medication error rate of 6.67%. Findings include:1. Observation and interview on 11/20/25 at 8:40 a.m. with RN C while she prepared and administered resident 31's morning medications revealed:Resident 31's November 2025 medication administration record (MAR) revealed a 10/13/25 physician's order that read: Takes medications crushed in applesauce. RN C stated that within the past three months, resident 31 had a decline in her swallowing abilities, which had prompted the physician's order for the resident to have her medications crushed if needed.RN C crushed all 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.
- Potential for harm · D2025-11-20 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, interview, record review, and policy review, the provider failed to follow infection control practices to ensure: *Three of five observed certified nurse aides (CNA) (E, H, and D) removed their personal protective equipment (PPE) (gowns and gloves ) and performed hand hygiene (HH) (handwashing with soap and water or a hand sanitizer) before exiting two of two sampled residents' rooms (3 and 21) who required transmission-based precautions (infection control measures such as the use of PPE and HH used to prevent the spread of infection (TBP).*Two of two observed CNAs (F and P) performed HH before putting on PPE and providing contact care for one of one sampled resident (31) who required TBP. *One of one observed wound care nurse (O) performed HH before opening new dressing supplies and applying the ordered dressing on one of one sampled resident (3) who required enhanced barrier precautions (EBP) related to a skin wound.*One of one registered nurse (RN) (I) removed her gloves and performed HH before opening new dressing supplies and applying the ordered dressing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-12-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the provider failed to properly label foods and discard foods on or before the manufacturer's best-by date, and failed to maintain the following kitchen items in a clean and sanitary manner: *In the kitchenette: -The flattop grill. -The grease trap drawer beneath the flattop grill. -The juice dispenser. -The overhead ventilation hood panels. *In the main kitchen: -The ceiling and ceiling vents throughout the kitchen. -The grease trap drawer beneath the flattop grill. -The deep fat fryer and the spaces in between the fryer and the adjacent equipment. Findings include: 1. Observation on 12/17/24 at 1:27 p.m. in the kitchenette revealed: *The flattop grill was stained with a burnt-on substance. *The grease trap drawer beneath the flattop grill contained a thick brown sludge of burnt food and grease. *There was a layer of dust buildup on the overhead ventilation hood panels. *There was an unidentified white growth inside the grape juice dispenser. 2. Continued…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-19 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, and policy review, the provider failed to ensure four of sixteen sampled residents (4, 8, 21, and 22) had their care plans updated, and revised promptly to reflect their current status and care needs. Findings include: 1. Observation on 12/17/24 at 3:42 p.m. in resident 4's room revealed: *There was an oxygen concentrator machine next to her sink. *She was using the portable oxygen machine at the time. -The flow rate was set at 2L/min (liters per minute) via nasal cannula. Review of resident 4's electronic medical record revealed: *There were two physician's orders related to her supplemental oxygen: -Oxygen 1-10 liters to be applied PRN [as needed] via NC [nasal cannula] or high flow NC to maintain SPO2 [oxygen saturation] above 90% as needed for hypoxia. Ordered on 6/30/23. -Oxygen 1-10 liters to be applied PRN via NC or high flow NC to maintain SPO2 above 90% three times a day. Ordered on 6/30/23. *Her care plan included the following intervention: -Apply oxygen PRN 1-5L NC to maintain oxygen level above 90%. Date initiated 2/17/20.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (21) who eloped (left the facility without staff knowledge) when a visitor exited the building. This citation is considered past-noncompliance based on review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's submitted SD DOH FRI regarding resident 21 revealed: *On 10/29/24 at 2:10 p.m., resident 21 followed an unidentified visitor out the front door of the facility. *The visitor had used a key fob to unlock the door and once in the parking lot the visitor realized resident 21 was a resident. *The visitor assisted the resident back into the lobby of the facility where staff were present. -Upon his return, the resident was assessed with no injuries and was dressed appropriately for the weather that day. -At the time of the elopement, resident 21 was in the main lobby of the facility attending a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to follow their Resident Weight policy and notify the registered dietitian (RD) and begin follow-up for one of one sampled resident (34) who experienced a significant weight loss. Findings include: 1. Observation on 12/17/24 at 3:37 p.m. revealed resident 34: *Was asleep in a group/activity room recliner with a hat and glasses on. *His clothes were loose-fitting. 2. A review of resident 34's medical record revealed: *He was admitted on [DATE]. *His 10/18/24 Brief Interview of Mental Status (BIMS) assessment score was 99, indicating he had not participated or was unable to participate in the assessment. *His diagnoses included vascular dementia (a type of dementia caused by reduced blood flow to the brain) with anxiety, cerebral infarction (stroke), and depression. *Review of the resident's weight records revealed: -On 10/10/24, he weighed 186.4 pounds. -On 11/2/24, he weighed 185.4 pounds. On 11/9/24, he weighed 178.6 pounds.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 follow their policy related to oxygen administration for two of five sampled residents (4 and 12) who received oxygen therapy: *Resident 4's oxygen tubing was not dated. *Resident 12's oxygen tubing was not changed monthly per facility policy. *Resident 4's nasal cannula was observed on the floor during one of three observations. *Resident 4's foam filter on the back of the oxygen concentrator machine had a buildup of dust. Findings include: 1. Observation and interview on 12/17/24 at 3:42 p.m. with resident 4 in her room revealed: *She was wearing a nasal cannula and using a portable oxygen tank. That tubing was not dated. *There was an oxygen concentrator machine next to her sink. -The foam filter on the back of the machine had a buildup of dust and fuzz. -The nasal cannula for that machine was on the floor. 2. Observation on 12/18/24 at 9:39 a.m. in resident 12's room revealed: *There was a section of extension tubing from the oxygen concentrator machine to the water chamber with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-30 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, review of the 8/29/23 Required Healthcare Facility Event Reporting form, and policy review, the provider failed to investigate and report in a timely manner an injury of unknown origin for one of one sampled resident (32). Findings include: 1. Observation and interview on 8/29/23 at 11:15 a.m. with certified nurse aide (CNA) E and CNA F and resident 32 in her room revealed: *The resident was lying in bed. -There were bilateral side rails on her bed, one fall mat on the floor next to one side of her bed, and a second fall mat on the floor at the foot of her bed. *A sign near the head of her bed indicated she was at risk for falls. *CNAs E and F transferred the resident with a mechanical lift from her bed to her wheelchair. -The staff stated the wheelchair was new to the resident. *The resident's left hand was wrapped with a gauze dressing. -A portion of the skin that was visible on her left thumb appeared black-colored and dry-looking. *CNA F confirmed the resident had injured her left hand a few weeks earlier but was not certain what…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-30 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the provider failed to ensure the following: *Care-specific details regarding one of one sampled resident's (32) skin condition and skin treatment had been documented in that resident's medical record. *One of one registered nurse (RN) C had not implemented a discontinued physician-ordered skin treatment for one of one sampled resident (32). *One of one sampled resident's (32) physician had been notified of her worsening skin condition. Findings include: 1. Observation and interview on 8/29/23 at 10:30 a.m. with RN D in resident 32's room revealed: *There were multiple areas of impaired skin integrity that varied in size and shape that were observed after RN D removed the dressing on the resident's left hand. *The areas observed were: -On the top of the resident's hand near her knuckles and near where the top of her hand and wrist had met. -On either side of the base of the palm of her hand and at the center of her wrist just below the palm. -On her thumb, index and pinky fingers. *The individual areas varied in size…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$47,655 in federal fines across 3 penalties.
- $9,568 — penalty dated 2025-01-27
- $30,069 — penalty dated 2024-12-19
- $8,018 — penalty dated 2024-03-06
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in SD
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the South Dakota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 43A038. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-20, 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.