Avantara Arrowhead

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.

50.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 21.6% 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 37 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% 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.

Staffing

How full it usually is: this home is certified for 68 beds and averages 59.3 residents a day — about 87% occupied, or roughly 9 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 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.98 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 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 3.27 hrs/resident/day on weekends vs 3.63 on weekdays — 10% thinner on weekends. RN hours go from 1.11 to 0.68 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 76% 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.

45 citations, most serious first. The 20 most serious are shown; the remaining 25 are one tap away and print in full.

• Actual harm · Gcited before2026-06-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  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 A. Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to ensure physician's orders were entered in one of one resident's (57) electronic medical record (EMR) and implemented to mitigate that resident's risk for hospitalization. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include:1. Review of the provider's 3/16/26 submitted SD DOH FRI final report regarding resident 57 revealed that physician HH's 3/6/26 orders were noted (acknowledged as being read, understood, and entered in resident 57's EMR) by assistant director of nursing (ADON) P on that same date. The orders were not cross-checked by a second nurse per the provider's revised 11/18/25 Following Physician Orders policy. The provider's investigation confirmed that ADON P only noted and entered physician HH's 3/6/26 medication orders for resident 57 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 · Past Non-Compliance
• Actual harm · Gcited before2025-11-06 · 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 South Dakota Department of Health (SD DOH) facility-reported incident (FRI) reviews, interviews, record review, and policy review, the provider failed to ensure the safety of three of eight sampled residents (1, 2, and 3) who had incidents of falls related to equipment use between 9/11/25 and 11/5/25. The manufacturer's instructions and policies for safe use of the resident care equipment had not been followed by the staff. Findings include: 1. Review of a 10/24/25 SD DOH FRI revealed that resident 1 had fallen out of a bath chair in the bathing room. The root cause identified for that fall was certified nurse aide (CNA) C failing to secure the bath chair's safety belt around the resident's waist while the resident was seated in that chair. After bathing the resident, CNA C moved the unsecured resident who was sitting in the bath chair out of the whirlpool bathtub. The resident leaned forward in the bath chair, causing her to fall forward out of the chair and onto the bathing room floor. Resident 1 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-09-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  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 record review, interview, and policy review, the provider failed to ensure quality care by not promptly implementing physician-ordered treatments for one of one sampled resident (69) with a physician-ordered negative pressure wound (NPWT) and antibiotic medication treatment. Findings include: 1. Review of resident 69's electronic medical record (EMR) revealed:*Her admission date was 3/25/25.*Her 3/31/25, 7/1/25, and 7/29/25 Brief Interview of Mental Status assessment scores were a 15, which indicated her cognition was intact.*She was hospitalized from [DATE] through 7/23/25 and again from 8/7/25 through 8/22/25.*Hospice (a program for terminally ill individuals that focuses on comfort and symptom management) care was initiated on 8/23/25.*She passed away at the facility on 8/24/25. *Her 3/25/25 admission diagnoses included hemiplegia and hemiparesis (partial paralysis affecting one side of the body) following cerebral infarction (brain tissue death caused by a severe and prolonged lack of blood flow)…

  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 before2025-09-11 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the provider failed to identify and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) preventative interventions for residents identified at risk for developing pressure ulcers for:*One of one sampled resident (31) who developed a pressure ulcer to her right heel, left upper buttocks, and left foot.*One of one sampled resident (11) who developed a pressure ulcer to his left lower and left upper buttocks.Findings include:1. Observation and interview on 9/9/25 at 9:22 a.m. with resident 31 in her room revealed:*There was a sign on resident 31's door that indicated she was on enhanced barrier precautions (personal protective equipment, such as gloves and a gown was to be worn with all close contact resident care) (EBP).*She had an air mattress on her bed.*She was lying in bed on her left side.*She had two Prevalon boots (a cushioned boot that floats the heel off the surface of the mattress, to help reduce…

  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 before2025-09-11 · 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 observation, interview, record review, and policy review, the provider failed to ensure: Interventions were implemented or updated to mitigate falling incidents for one of one sampled resident (14) identified at risk for falling who fell and sustained facial bruising and to have completed and documented a thorough investigation of that fall.Findings include:1. Observation on 9/9/25 at 8:46 a.m. of resident 14 in her room revealed she was lying on her side in bed. There was purple colored bruising beneath and above her right eye, extending to her forehead hairline. The resident stated she had fallen but was not sure how that had occurred. Her bed was low to the floor. Her call light was held inside the top closed drawer of a three-drawer plastic storage container near the head of her bed. A fall mat was folded against the wall on her roommate's side of the room. A walker and a wheelchair were also by that wall. Observation and interview on 9/9/25 at 11:35 a.m. with occupational therapist (OT) X in resident 14's room revealed she was encouraging the resident to reach towards…

  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 before2025-09-11 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  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 pain management interventions were implemented and effective for one of one sampled resident (6).Findings include:1. Observation and interview on 9/9/25 at 9:53 a.m. in resident 6's room revealed he was lying on his back in bed wearing a hospital gown. He had a U-shaped pillow around the back of his neck. The resident had a grim expression on his face, and he strained to answer simple questions. He complained of being cold. Observation on 9/9/25 at 12:00 noon outside of resident 6's room revealed he was overheard telling an unidentified caregiver, I wish that nurse would come. I need that oxy [oxycodone, pain medication that is a controlled medication meaning at risk for abuse and addiction].Observation on 9/9/25 at 12:03 p.m. revealed licensed practical nurse (LPN) E entered resident 6's room. She explained to him that he had a physician's order for Tylenol, but there was no order for him to have oxycodone. LPN E…

  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 before2025-03-05 · 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 interview, record review, observation, South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, and policy review, the provider failed to ensure an assessment, physician notification, initiation of a skin treatment, and monitoring for one of one sampled resident's (2) newly discovered skin injury. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of resident 2's electronic medical record (EMR) revealed: *Her admission date was 12/12/23 and her 2/21/25 Brief Interview for Mental Status (BIMS) assessment score was 0 which indicated she was severely cognitively impaired. *Her diagnoses included: hemiplegia, stroke, stage IV chronic kidney disease, diabetes, vascular dementia, and anxiety. She had a suprapubic catheter (tube inserted into the bladder to drain urine) related to acute cystitis (inflammation of the bladder). *She had a change in her medical condition on 2/17/25 and received intravenous (IV) fluids and an IV antibiotic…

  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 · Past Non-Compliance
• Actual harm · Gcited before2024-07-10 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure the physician and family had been notified for a change in condition for one of one sampled resident (1) following a laceration to her left leg. Findings include: 1. Review of resident 1's medical record revealed: *She had been admitted on [DATE]. *Her (Brief Interview for Mental Status (BIMS) was 11 which indicated her cognition was moderately impaired. *Her diagnoses included paroxysmal atrial fibrillation, abrasion left lower leg, secondary malignant neoplasm of bone marrow, acute kidney failure, malignant neoplasm of unspecified site of left female breast and congestive heart failure. * She received a skin tear to her left lower leg on 6/21/24. *The on-call care provider was notified of her left leg laceration and agreed it could be addressed in the facility. *Resident 1's son was informed of her left leg laceration and provider's recommendation. *A physician's notes on 6/21/24 stating Staff called Friday 6/21 10 p.m. Staff…

  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 before2024-07-10 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to assess, and implement preventative pressure injury interventions for one of one sampled resident (2) who was identified as at risk for pressure injuries and developed a pressure injury. Failure to assess and implement pressure injury prevention interventions potentially contributed to resident 2's development of a pressure injury. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. A review of facility reported event (FRI) for resident 2 revealed: *He admitted to facility on 6/5/24. *He was at risk for skin breakdown at admission. *He should have been turned and repositioned every two hours. *Only intervention in place at admit was heel lift boots for skin integrity. 2. A review of resident 2's electronic medical record (EMR) revealed: *He was admitted…

  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 · Past Non-Compliance
• Actual harm · G2024-05-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  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 ensure: *A bowel management program was monitored for one of one sampled resident (9) who had multiple diarrhea consistency stools and unintentional weight loss. *Appropriate and necessary notification of resident 9's physician assistant (PA) H and registered dietician (RD) I about the consistency and amount of her stools. Findings include: 1. Observation on 5/13/24 from 5:30 p.m. to 6:00 p.m. of resident 9 while in the dining room during the evening meal revealed: *She was sitting in a wheelchair and had a small, frail, bony appearance. *She was eating a meal from a fast-food restaurant. Interview on 5/14/24 at 9:30 a.m. with resident 9 revealed: *She felt she was losing weight because she poops all the time and everything goes right through me. -She stated she was having a watery bowel movement (BM) with every toileting and often had incontinent (uncontrolled) BMs. -She stated, I have had water poop for a long time. I…

  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 · F2026-06-22 · 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 South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), record review, and interview, the provider failed to ensure an effective, comprehensive quality assurance and performance improvement (QAPI) program was implemented to track and measure performance; systematically analyze underlying causes of a systemic quality deficiency; develop and implement corrective actions or performance improvement activities; and evaluate the effectiveness of the corrective actions, and to revise those actions as needed.Findings include:1. Review of a 3/20/26 SD DOH FRI revealed that the incident investigation substantiated neglect occurred when the facility failed to provide resident 56 incontinence care. 2. Review of a 3/27/26 SD DOH FRI revealed that the incident investigation substantiated that the facility failed to provide resident 55 incontinence care. 3. Review of a 4/19/26 SD DOH FRI revealed that the incident investigation substantiated that the facility failed to provide resident 37 incontinence care. 4. The provider's corrective action plan for the above FRIs…

  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 plan of correction
• Potential for harm · Ecited before2026-06-22 · tag F0554 — pattern
  Allow residents to self-administer drugs if determined clinically appropriate.
  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:*Resident's medication self-administration assessment was completed, and a physician's order was obtained for two of two sampled resident (63 and 43) who was not assessed to determine her ability to safely self-administer her medications or had a physician's order to self-administer those medications.*Resident's medication were not stored in a bedside lockbox for two of two sampled residents (10 and 43) per facility policy and self-administration evaluations. Findings included: 1.Observation and interview on 6/16/26 at 10:30 a.m. with resident 63 in her room revealed she had a small plastic cup containing five pills sitting on her nightstand. Resident 63 stated she was unsure what the medications were for and reported they had been sitting on her nightstand all morning, as she had an upset stomach and had not yet taken her medications. 2. Review of Resident 63's electronic medical record (EMR) revealed she admitted 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 Rights Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · Ecited before2026-06-22 · 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

  A. Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, and record review, the provider failed to ensure one of one resident (56) was provided timely incontinence (involuntary urine or bowel leakage) care by one of one certified nurse aide (CNA) (KK). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.Findings include:1. Review of the provider's 3/20/26 submitted SD DOH FRI final report revealed that on 3/20/26 at 2:45 p.m. at resident 56's medical appointment, it was identified that the resident's incontinence brief was saturated. The appointment was not completed.CNA KK was responsible for resident 56's care that day. The resident required staff to check and change his incontinence brief. According to the SD DOH FRI, resident 56's incontinence brief was last checked at 8:00 a.m. by CNA KK, and the brief was dry.Former medical records coordinator LL transported resident 56 to the above medical appointment. She asked CNA KK to check 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · Ecited before2026-06-22 · 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 South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, and interview, the provider failed to adhere to professional nursing standards of practice to ensure one of one resident's (99) pain medication was administered according to the physician's order by one of one licensed practical nurse (LPN) (H).This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.Findings include: 1. Review of the provider's 5/4/26 SD DOH FRI revealed that during the provider's investigation of a separate, unsubstantiated neglect allegation that involved LPN H, a medication error was identified that occurred on 4/30/26. It was determined that LPN H administered an incorrect dose of pain medication to resident 99. The provider submitted a FRI regarding this incident to the SD DOH because LPN H alleged that insufficient staffing contributed to her making that medication error. 2. Review of resident 99's electronic medical record (EMR) revealed her admission date was 4/30/26 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.

  Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
• Potential for harm · Ecited before2026-06-22 · 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

  Based on observations, interviews, and policy review, the provider failed to ensure one of five certified nurse aide (CNA) (GG) wiped down a mechanical lift after resident use with disinfectant, two of five CNAs (L and GG) performed hand hygiene after resident cares or before putting on personal protective equipment (PPE), three of five CNAs (U, L, and S) had access to and could state how to use PPE per facility policy, and two of five CNAs (FF and L) maintained clean resident personal hygiene items in two of two sampled whirlpool rooms. Findings include:1. Observation on 6/16/26 at 9:45 a.m. in resident 17's room revealed CNA GG completed a full body lift (a mechanical lift and sling used to lift a person's full body) transfer to weigh resident 17. After the lift was completed, CNA GG moved the mechanical lift to the hallway outside of resident 17's door. She did not perform hand hygiene (cleaning hands with alcohol-based hand sanitizer or washing with soap and water), then went into another resident's room. 2. Observation on 6/17/26 at 4:06 p.m. in the [NAME] hallway soiled…

  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 plan of correction
• Potential for harm · D2026-06-22 · tag F0550 — failed to protect resident dignity and rights — isolated
  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 South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and record review, the provider failed to ensure that one of one resident's (62) preference for incontinence care was observed by one of one certified nurse aide (CNA) (Y).This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.Findings include:1. Review of the provider's 6/12/26 submitted SD DOH FRI final report regarding resident 62 revealed that on 6/12/26 at 10:15 p.m., resident 62 advised CNA Z that she needed to use a bedpan to urinate in. Resident 62 stated that earlier that same evening, CNA Y refused to accommodate the resident's request to use a bedpan and was told by CNA Y to urinate in her incontinence brief instead.CNA Z provided resident 62 a bedpan to use per the resident's request. When CNA Z returned to resident 62's room a short time later to check on her, CNA Y was in the resident's room. Resident 62 identified CNA Y as the CNA who, earlier that same evening, denied the resident's…

  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 · Past Non-Compliance
• Potential for harm · D2026-06-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  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 that services were provided to improve or maintain the range of motion for one of three sampled residents (37), who developed a contracture (a permanent tightening or shortening of muscles, tendons, skin, or other tissues that causes joints to become stiff) of her left hand while residing in the facility, did not receive therapy services in the past 12 months, a physician's order was in place for staff to follow regarding resident 37's brace management and use, and the care plan included goals and interventions to address resident 37's left-hand contracture and brace use. Findings include:1. Observation on 6/17/26 at 2:57 p.m. of resident 37 in her room revealed she was awake in bed, nonverbal, but followed with her eyes and smiled. She partially extended her left arm from her side and reached out her hand. This surveyor gently shook her hand and explained why she was there. She was noted to have a left-hand contracture; no brace…

  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 plan of correction
• Potential for harm · Dcited before2026-06-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when 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 observation, interview, record review, policy review, and manufacturer's user guide review, the provider failed to ensure infection control practices were followed for the cleaning of a continuous positive airway pressure (CPAP) machine for one of one sampled resident (34).Findings included:1.Observation and interview on 6/16/26 at 10:46 a.m. of resident 34 in his room revealed there was a CPAP machine on top of his nightstand. The water chamber remained connected to the CPAP machine and contained water. After removing the water chamber, a dried white film was visible on the interior and exterior sides and the back area where the water chamber connects to the CPAP machine. The CPAP housing where the water chamber inserts into it had brown spots and dried white film on the bottom and a portion of the sides. The filter located at the back of the CPAP machine was dark brown.Resident 34 stated the staff were not cleaning the CPAP machine or water chamber daily or weekly. He also stated the staff had not…

  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 plan of correction
• Potential for harm · D2025-12-10 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interviews, and record review, the provider failed to ensure two of two registered nurses (RN) (D and E) had reported allegations of suspected abuse for two of two sampled residents (1 and 2). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include:1. Review of the provider's SD DOH FRI submitted on 12/1/25 at 6:52 p.m. revealed that resident 1 had informed RN E that he had felt the care that was provided by agency-certified nursing assistant (CNA) K was rough. Resident 1 commented to his son, over the phone, about the care that was provided. Administrator A and social services director L had interviewed the resident, and he reported to them that he had pain with the care provided by agency CNA K. RN E had talked to agency CNA K and instructed her to be more careful with resident 1 during his care. Agency CNA K was blocked…

  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 · Past Non-Compliance
• Potential for harm · Dcited before2025-12-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  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 the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and record review, the provider failed to ensure:*One of one agency certified nursing assistant (CNA) (O) followed the care plan regarding cares in pairs for one of one sampled resident (3).*One of one CNA (G) followed the care plan regarding the correct transfer device for one of one sampled resident (4), which resulted in a fall. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include:Review of the provider's SD DOH FRI submitted on 11/14/25 at 7:30 a.m. revealed that resident 3 indicated she was touched inappropriately by agency CNA O earlier that morning on 11/14/25. Assistant director of nursing (ADON) P assessed resident 3 following the allegation. Review of resident 3's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) showed she was cares in pairs due 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.

  Quality of Life and Care Deficiencies · Past Non-Compliance

“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

$153,583 in federal fines across 6 penalties.

• $70,720 — penalty dated 2025-11-06
• $42,705 — penalty dated 2025-09-11
• $8,112 — penalty dated 2025-03-05
• $8,018 — penalty dated 2024-07-10
• $11,333 — penalty dated 2024-07-10
• $12,695 — penalty dated 2024-05-15

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 LEGACY HEALTHCARE — 89 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 →

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

CMS files one row per role, so the 22 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

About 74% 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. This home reported $765K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 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

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