Sanford Care Center Vermillion
125 S Walker Street, Vermillion, SD 57069 · Non profit - Corporation · 66 certified beds · (605) 677-3500 Medicaid only — no Medicare
This home has serious findings on its record. Read them closely before you consider it.
- 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 Jan 2026
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- the CMS record shows $44,577 in federal fines (most recent 2024-07-01)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 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 | 22.9% | 21.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.9% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.3% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.6% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.4% | 5.7% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.0% | 5.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 18.2% | 19.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 26.7% | 17.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.6% | 4.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.9% | 25.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.7% | 24.6% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.39 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.94 | 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 <0.01 therapist hours per resident per day in 2026Q1 — more than 0% 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 66 beds and averages 61.8 residents a day — about 94% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.97 hrs/resident/day on weekends vs 3.45 on weekdays — 14% thinner on weekends. RN hours go from 0.87 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
11 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · Jcited before2024-07-01 · 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 observation, interview, and record review the provider failed to provide adequate supervision for 1 of 1 resident (20) to prevent actions of self-harm. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on [DATE] at 2:12 p.m. to administrator A for F689 and director of nursing B for F689 Accidents related to the prevention of his self-harm. *Observation on [DATE] of resident 20 in his room revealed he had multiple open areas, some of which were actively bleeding on his bilateral lower legs while holding a sharp instrument. *Multiple staff interviews revealed they were aware that he had various sharp tools in his possession and used these sharps to cut himself to remove bugs he believed were under his skin. *Record review of resident 20's care plan revealed he was allowed to have sharps he purchased in his possession to remove perceived bugs from his skin. On [DATE] at 4:23 p.m., administrator A provided the survey team with a written plan for…
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 before2026-01-29 · 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), record review, interview, observation, and policy review, the provider failed to protect the safety of two of two sampled resident (1, and 2) identified as at risk for elopement (leaving the facility without staff knowledge) who had exited a secured door and crawled out of a room window and left the building without staff supervision. Findings include:1. Review of the 11/22/25 SD DOH FRI report regarding resident 1 revealed:*Resident 1 was admitted to the facility on [DATE].*On the night of 11/2/25:-Resident 1 was wandering around at his baseline looking for exits.-At approximately 12:40 a.m. the south door alarm goes off.-Resident 1 is in the south hall walking back toward the nurses station/central lobby.-Nurse [registered nurse (RN) B] heads down to the far south door to turn off the alarm.-Resident 1 turns to follow and immediately pushed open the south door and leaves the building at 12:42 a.m.[RN B] Unable to see resident…
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 · G2024-07-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 observation, interview, and record review the provider failed to deliver appropriate wound care, assessment and monitoring for one of one (20) sampled residents observed with wounds. Findings include: 1. Observation and interview on [DATE] at 9:29 a.m. with resident 20 revealed: *He was sitting on the edge of his bed scratching at his leg. *He had multiple open areas with some active bleeding on his bilateral lower legs and bandages on some of them. *There was a white towel under his bare feet with dried blood on it and another lying to his left with dried blood on it. *Bandage wrappers were on the floor by his feet. *He stated his legs are better because he has been taking care of them. *He stated he kept his tools in alcohol. *He stated he had good medicine here but the nurse took it from him and said it was dangerous and he could not have it. *He stated he was doing okay for the shape he was in. *His shower has two discolored towels on the floor that appeared to have been wet then dried multiple…
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 · D2026-01-29 · 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 South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, employee file review, and policy review, the provider failed to protect one of one sampled resident (3) from verbal abuse who had profanity verbalized toward her by certified nursing assistant (CNA) H.Findings include:1. Review of the 1/12/2026 SD DOH FRI report revealed:*A report was made on 1/12/26 involving [resident 4] who expressed concerns of verbal abuse by a staff member [CNA H] to another resident [resident 3].*CNA H was interviewed by director of nursing (DON) A and clinical care leader (CCL) F on 1/12/26 and then sent home and remained on suspension pending the investigation.*Resident 3's date of admission to the facility was on 12/2/25.*Resident 3's most recent Brief Interview for Mental Status (BIMS) assessment score was 3 indicating severe cognitive impairment.*Resident 3 had pertinent diagnoses of dementia, hearing loss, chronic kidney disease stage 3.*Resident 4's date of her admission to the facility was on 2/1/24.*Resident 4's most recent BIMS assessment score was 15…
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 · Ecited before2025-10-02 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the provider failed to follow industry accepted food safety standards to ensure proper glove use by cook (E) while preparing and serving residents' food during one observed meal service according to the provider's policy.Findings include:1. Observation on 9/30/25 at 11:40 a.m. of cook E while preparing residents' food in the dining room kitchenette revealed:*With her gloved hands she:-Touched the residents' menu slips.-Opened a bag of bread and pulled slices of bread out of the bread bag and placed them on top of the hot grill.*She then removed her gloves, washed her hands, and put on a new pair of gloves. With those gloved hands she:-Opened the refrigerator door, removed a bag of sliced cheese, and placed it on the counter beside the hot grill.-Touched the bread slices on the hot grill and slid them around.-Opened the bag of cheese and placed cheese slices on those slices of bread.-Opened the refrigerator door and removed a zip lock bag of two precooked burger patties.-Placed those burger patties on a plate.*She then removed her…
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 · D2025-10-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Number of residents sampled: Number of residents cited: Based on observation, interview, record review, and policy review the provider failed to ensure a formalized dining assistance program was conducted with identified family member of resident (18) who assisted resident 11 with dining. The provider also had no documentation of training for any other resident family members or visitors who offered dining assistance. Findings include: 1. Observation on 9/30/25 at 12:15 p.m. of in the dining room revealed: *A visitor used resident 18's utensils in her right hand and assisted him with eating. She then turned to her right and picked up resident 11's utensils with her right hand, and assisted resident 18 with eating. *The visitor did not wash her hands after she assisted resident 18 with eating before she assisted resident 11 with eating. 2. Interview on 9/30/25 at 12:30 p.m. with certified nursing assistant (CNA) C revealed:*She and a medication aid assisted residents with eating their meals. Resident 18's wife came in to the facility everyday to help her husband with eating, 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.
- Potential for harm · F2024-07-01 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the provider failed to ensure the facility assessment had addressed the staffing resources needed to ensure appropriate care and services were available to the residents. Findings include: 1. Review of the provider's undated facility assessment revealed: *The assessment did not address their resources for staffing needs. *The assessment was an eleven-page excel spreadsheet that included: -An overall monthly trending analysis of census that indicated it was a 64-bed nursing facility that had. --One dementia care unit of 12 beds. --General units of 52 beds combined. --A January through May overall census average of 58. -A Physical Function and Care Needs analysis of residents including: --Assistance needed with bathing, dressing, transferring, toilet use, eating, and mobility. --Bowel and bladder status. --Cognitive disabilities. --Skin integrity. --Cultural sensitivity, religious and ethnicity care recognition. --Communication. --Conditions. --Medication use. --It had not specified how many staff were needed to care for the residents or how they…
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 · D2024-07-01 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review interview, and policy review the provider failed to have a physician's order in place consistent with one of one (2) sampled resident's advance directive. Findings include: 1. Review of resident 2's electronic medical record (EMR) revealed: *The banner at the top of his EMR when opened on [DATE] displayed DNR [do not resuscitate]. *He had a full code (permission for life-sustaining measures, including resuscitation) order dated [DATE]. *Interview on [DATE] at 5:10 p.m. with director of nursing (DON) B and Minimum Data Set (MDS) nurse C revealed: DON B stated she did not have a current order for resident 2's DNR and to talk to MDS nurse C. *MDS nurse C stated she had faxed the physician on [DATE] to request an order but did not have one in resident 2's chart. Review of provider's [DATE] advance directive policy including cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) procedure revealed: *1. Advance directive orders are to be reviewed with resident/healthcare…
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 · D2024-07-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on observation, interview and record review the provider failed to properly store eye drops, lotions, gels, creams, lotions, and ointments for 2 of 20 residents (1 and 16). Findings include: 1. Observation and interview on 6/25/24 at 10:16 a.m. with resident 16 in his room revealed: *He had 2 boxes of eye drop medication on his bedside table. One was latanoprost (for pressure inside the eye) and one was Carboxmethylcell. *He stated they were left in his last night by the nurse who didn't come back to pick them up. 2. Observation on 6/25/24 at 10:34 a.m. of resident 2's room revealed: *A container that had anti itch lotion, Vicks vaporub, vaseline, Aquaphor, aloe gel, simple saline wound wash and Metholatum in it, on a stand next to his recliner. 3. Interview on 6/25/24 at 10:23 a.m. with licensed practical (LPN) L revealed: *She stated maybe resident 16's eye drops were left in his room due to his positive coronavirus disease (COVID-19) test but was unsure. *He was cognitively intact, which 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.
- Potential for harm · Dcited before2024-07-01 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to maintain the temperature of the memory care unit (MCU)'s pantry refrigerator below 41 degrees Fahrenheit (F). Findings include: 1. Observation on 6/25/24 at 3:33 p.m. of the MCU's pantry refrigerator revealed: *The thermometer inside the refrigerator read 46 degrees Fahrenheit (F). *The Refrigeration Temperature Log located on a clipboard hanging on the wall next to the refrigerator had no documented refrigerator temperatures for December 2023 and no other monthly logs were found. *Contents of the MCU's pantry refrigerator included: -Numerous eight fluid-ounce soda cans. -Six opened 48-ounce containers of juice labeled Refrigerate after opening. -Three four-ounce Mighty Shakes labeled Thaw at or below 40 degrees F. Use thawed product within 14 days. Keep Refrigerated. 2. Interview on 6/25/24 at 3:40 p.m. with certified nursing assistant (CNA) I revealed she: *Had not normally worked on the MCU. *Was not sure whose…
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 · D2024-07-01 · 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, policy review, and manufacturer's instructions review, the provider failed to clean and disinfect one of one community shared blood glucose meter for two of two sampled residents (44 and 48) that resulted in a potential increased risk for bloodborne pathogen infections. Findings include: 1. Observation and interview on 06/25/24 at 4:02 p.m. and 4:18 p.m. with registered nurse (RN) F revealed: *RN F completed a blood glucose check for resident 44. *She then wiped the blood glucose meter with a gray top Sani-cloth (germicidal) wipe and placed the blood glucose meter on the medication cart. *RN F stated that glucose meter was to be first wiped off with a wipe to clean visible blood or fluids off the glucose meter and then with another one to wet it and let it dry for two minutes. *She did not know if there was a policy on how to clean a glucose meter. *She used that same blood glucose meter to check resident 48's blood glucose and again wiped it with a gray top Sani-cloth wipe and placed it on the medication cart. 2. Interview on 6/27/23…
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
$44,577 in federal fines across 1 penalty.
- $44,577 — penalty dated 2024-07-01
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 43A098. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-10-02, 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.