Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oglala Sioux Lakota Nursing Home during CMS and state inspections, most recent first.
The facility failed to dispose of foods past their best by/use by dates and failed to store scoops for flour, breadcrumbs, and sugar in a way that prevented cross contamination. Surveyors found a half-empty jug of apple cider vinegar and a container of barley beyond their dates, and observed scoops laying in dry goods containers; the DM confirmed the items were past date and the scoop placement was improper.
An inaccurate MDS was completed for one resident when weight loss was marked yes despite EMR weights showing only minimal loss and no physician-prescribed weight-loss regimen. Another resident’s quarterly MDS failed to reflect a diuretic and antipsychotic in Section N, even though the MAR showed bumetanide and quetiapine use along with an antidepressant, anticoagulant, and antibiotic.
The facility failed to submit a required investigative report within the required 5 working days for a resident’s fall with injury. A resident fell, sustained a forehead laceration and elbow skin tear, was sent to the ER, and returned the same day with sutures. The facility’s report was dated 6 working days after the incident, and the DON confirmed it was the report sent to the State Agency.
The facility failed to implement fall prevention interventions for three residents with cognitive impairments and high fall risk. Despite multiple falls, including one resulting in a hip fracture, no new interventions were put in place, and fall huddles were inconsistently conducted. This lack of action left residents vulnerable to repeated falls.
A resident experienced severe weight loss over six months, dropping from 113.3 lbs to 98.7 lbs, without new interventions being implemented. Despite being on a mechanically altered diet and having a care plan for potential nutritional problems, the facility did not update the care plan with new strategies to address the weight loss. The Registered Dietitian recommended continuing current interventions and offering snacks, but no new actions were taken, as confirmed by the DON.
The facility failed to dispose of expired food items and did not adhere to proper food storage practices, potentially affecting all 47 residents. Expired items were found in storage, and some food items were not labeled with dates. Additionally, the facility did not monitor food temperatures before serving, as required, which was confirmed by the Dietary Manager.
A facility experienced a medication error rate of 35.71% due to late administration of medications to three residents. Medications were administered beyond the one-hour window prescribed by facility policy, with reasons including staff running behind schedule and avoiding disturbing a resident in the morning. The delays were confirmed through observations and staff interviews.
A facility failed to follow its infection control policies, including daily cleaning of a PAP mask for a resident with muscular dystrophy, implementing Enhanced Barrier Precautions for a resident with dementia, and ensuring hand hygiene during care activities. Staff did not wear gowns during high-contact care for a resident with an open wound, and a Medication Aide did not perform hand hygiene between peri-care and medication administration.
A resident with dementia was transferred to the hospital without a complete written notice. The notice lacked the resident's name, a specific medical reason for the transfer, and contact information for the state LTC agency and ombudsman. The Social Services Director confirmed these omissions.
A resident with dementia experienced a decline in ADLs and significant weight loss, requiring a significant change MDS, which the facility failed to complete. The MDS Coordinator confirmed the oversight during a survey, indicating non-compliance with OBRA regulations and the RAI Manual.
A facility failed to complete and transmit a Discharge MDS for a resident with dementia who was hospitalized for dehydration. The MDS Coordinator confirmed that the required assessment was not completed within the mandated timeframe.
The facility failed to ensure accurate MDS assessments for two residents. One resident's use of a CPAP device was not documented, despite daily use, and another resident's anticoagulant medication was not recorded, despite an ongoing prescription for Xarelto. These inaccuracies were confirmed by the MDS Coordinator.
A resident with dementia, depression, and anxiety had a care plan that failed to address specific behavioral symptoms like yelling and hallucinations. The plan focused on medication management without including effective non-pharmacological interventions identified by staff, such as offering snacks and engaging in activities. The MDS Coordinator confirmed the care plan's lack of comprehensiveness.
A facility failed to update a resident's ADLs care plan to reflect their current needs. The resident's quarterly MDS assessment showed they required moderate assistance with eating and were dependent for oral hygiene, toileting, dressing, and personal hygiene. However, the care plan, last revised months earlier, indicated different levels of assistance. The MDS Coordinator confirmed the care plan was outdated.
A resident with severe cognitive impairment experienced prolonged periods without bowel movements due to the facility's failure to implement prescribed interventions. Despite having orders for various constipation medications, the resident did not receive them as needed, leading to extended periods without bowel movements. Interviews with staff confirmed the absence of a bowel protocol and insufficient documentation and action during these periods.
A resident identified as at-risk for wandering did not have a care plan or interventions in place to prevent elopement, despite facility policy requirements. The resident eloped twice in one day, and there was no evidence of 15-minute checks being conducted as part of fall interventions. Interviews confirmed that preventive measures were not implemented in a timely manner.
A facility failed to include necessary settings in a PAP device order for a resident with muscular dystrophy, as required by their CPAP/BiPAP support policy. The resident's records showed orders without specified settings, confirmed by interviews with an LPN and the DON. This deficiency was identified during a review of records and interviews, affecting one of two residents sampled for respiratory care.
A facility failed to attempt a gradual dose reduction for a resident on psychotropic medications, despite the resident showing no symptoms of depression and no noted behaviors. The facility's policy requires such reductions unless clinically contraindicated, but there was no documentation to support contraindication, and the Director of Nursing confirmed that a reduction should have been attempted.
Food Storage and Scoop Handling Deficiencies
Penalty
Summary
The facility failed to dispose of foods by their best by dates and failed to store scoops for dry goods in a manner to prevent potential cross contamination. During an observation in the kitchen dry storage area, surveyors found a half-empty jug of apple cider vinegar labeled best if used by 12/4/25 and a plastic container labeled barley with a use by date of 10/29/25. The Dietary Manager confirmed both items were beyond their use by dates and should be disposed of. Surveyors also observed a Rubbermaid container labeled flour with a plastic scoop laying in the flour, a Rubbermaid container labeled breadcrumbs with a plastic scoop laying in a bag of breadcrumbs inside the container, and a plastic container labeled sugar with a plastic scoop laying in the sugar. The Dietary Manager confirmed the scoops were laying with their handles in the flour, breadcrumbs, and sugar. The facility census was 36, and the issue was identified during observation, record review, and interview.
Inaccurate MDS Assessments for Weight Loss and High-Risk Drug Classes
Penalty
Summary
The facility failed to submit an accurate MDS for Resident 6. The annual MDS dated [DATE] listed the resident’s most recent weight as 132 pounds and marked weight loss as yes in Section K, item K0300, even though the resident was not on a physician-prescribed weight-loss regimen. Review of the resident’s documented weights in the EMR showed 132 pounds on 9/6/25, 133.5 pounds on 8/5/25, and 136.4 pounds on 3/8/25, which reflected only a 1.1% weight loss over one month and a 3.2% weight loss over six months. The MDS-RN confirmed on 12/17/25 that the EMR weights were the resident’s actual weights and that the 9/8/25 MDS should not have been marked yes for weight loss. The facility also failed to accurately complete Resident 32’s quarterly MDS in Section N, High-risk drug classes: Use and indication. The resident’s MAR for September 2025 showed administration of bumetanide daily for hypertension, quetiapine nightly, trazodone for anxiety disorder, rivaroxaban for atrial fibrillation, and Bactrim DS twice daily from 9/18/25 to 9/28/25. The quarterly MDS dated [DATE] indicated the resident took an antidepressant, anticoagulant, and antibiotic during the 7 days prior to the assessment, but Section N item N0450A stated the resident had not received an antipsychotic since the prior MDS dated 7/8/25. The MDS-RN confirmed on 12/17/25 that the assessment should have reflected that the resident was taking both a diuretic and an antipsychotic during the assessment period in addition to the other listed medications.
Late Submission of Fall Investigation Report
Penalty
Summary
The facility failed to submit its investigation within 5 working days for one resident’s fall with injury. Resident 41 had a fall on 10/26/2025 that resulted in a laceration to the forehead and a skin tear to the left elbow; the resident was sent to the emergency room and returned the same day with sutures to the forehead. The facility’s undated Abuse Prevention Policy stated that a written report would be provided to the State within five working days of the Administrator receiving the report. A facility-provided document detailing the fall showed a “Today’s Date” of 11/3/2025, which was 6 working days after the incident, and the DON confirmed that this document was the investigative report submitted to the State Agency regarding the fall.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to prevent falls for three residents, all of whom were at high risk for falls due to various health conditions. Resident 1, who had severe cognitive impairment and required substantial assistance for mobility, experienced two falls in January 2025, one of which resulted in a hip fracture requiring surgery. Despite these incidents, no new interventions were implemented, and there was no evidence of fall huddles being conducted to assess and address the causes of the falls. Resident 3, with moderate cognitive impairment and a history of multiple falls, experienced numerous falls between October 2024 and January 2025. The facility's documentation showed that while some fall huddles were conducted, many falls did not result in new interventions being put in place. The lack of consistent follow-up and intervention implementation left Resident 3 vulnerable to repeated falls, as evidenced by the numerous incidents recorded without corresponding preventive measures. Resident 2, who had severe cognitive impairment and was at high risk for falls due to factors such as wandering and balance problems, also experienced falls in December 2024. The facility's records indicated that no new interventions were developed following these falls, and the care plan remained unchanged. Interviews with staff confirmed the absence of updated interventions, highlighting a systemic issue in the facility's approach to fall prevention and risk management.
Failure to Implement Interventions for Severe Weight Loss
Penalty
Summary
The facility failed to implement new interventions to prevent significant weight loss for a resident, identified as Resident 20, who experienced severe weight loss over a period of three and six months. The resident's weight dropped from 113.3 pounds to 98.7 pounds over six months, representing a 12.89% loss, which is considered severe. Despite the resident's care plan indicating a potential for nutritional problems due to dementia with behavioral disturbance and Type 2 Diabetes Mellitus, and a goal to maintain weight within 5% of a baseline weight of 135 pounds, the facility did not update the care plan with new interventions to address the severe weight loss. The resident was on a mechanically altered diet due to loose teeth, and the care plan included monitoring for swallowing difficulties, providing supplements, and serving a diet as ordered. However, despite recommendations from the Registered Dietitian to continue current nutrition interventions and offer snacks, no new interventions were implemented after significant weight loss was noted. The Director of Nursing confirmed that no new interventions were put in place to mitigate the resident's severe weight loss, and the care plan was not updated accordingly.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to ensure that food items were disposed of or consumed before their best-by and use-by dates, and did not adhere to proper food storage and preparation practices, potentially affecting all 47 residents. During an initial kitchen tour, several expired food items were found in the dry food storage area, including nutrition drinks, gelatin, pudding mix, prune juice, and nacho cheese dip. Additionally, graham crackers were stored without a date, and a container of pickle relish and a can of crushed pineapple were improperly sealed or damaged. In the walk-in refrigerator, bread loaves, hamburger buns, and dinner rolls were not labeled with dates, and a partially consumed Gatorade bottle was stored above food items meant for residents. The Dietary Manager confirmed these items should have been dated and disposed of appropriately. The facility also failed to monitor food temperatures as required. Observations revealed that Cook-N did not check the temperatures of foods held in the steam table before serving them to residents. The routine process involved checking temperatures only after cooking and placing food on the steam table, not before serving, regardless of how long the food had been held. This practice was confirmed by both Cook-M and the Dietary Manager, who acknowledged that food temperatures should have been checked prior to serving to ensure safety.
Medication Administration Delays Result in High Error Rate
Penalty
Summary
The facility failed to administer medications at the correct times, resulting in a medication error rate of 35.71%, which is significantly higher than the acceptable threshold of less than 5%. This deficiency was observed in three out of five sampled residents. The facility's policy, revised in April 2019, mandates that medications should be administered within one hour of their prescribed time. However, observations and interviews revealed that medications for Residents 11, 43, and 98 were administered late by Medication Aides (MAs) due to various reasons, including the MA running behind schedule and a preference not to disturb a resident in the morning. Resident 98 was prescribed cephalexin to be administered at 7:00 AM, but it was given at 8:20 AM. Resident 43 was prescribed Miralax and omeprazole for 7:30 AM, but these were administered at 8:48 AM. Resident 11, who was in pain and crying out for help, had multiple medications prescribed for 8:00 AM, but they were administered at 9:22 AM. The delay in administering medications was confirmed through interviews with the MAs involved, who acknowledged the late administration and provided reasons for the delays.
Infection Control and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident 2, who was cognitively intact and had a primary diagnosis of muscular dystrophy, the facility did not follow its policy for cleaning the PAP mask. Observations revealed that the mask had light-colored debris and yellow residue, and the head strap was discolored. Despite the facility's policy requiring daily cleaning of the mask, interviews with staff confirmed that this was not being done. For Resident 22, who had severe cognitive impairment and a primary diagnosis of dementia, the facility failed to implement Enhanced Barrier Precautions (EBP) during high-contact care activities. Observations showed that staff did not wear gowns while performing personal care and wound care, despite the presence of a CDC EBP sign on the resident's door. Interviews with staff confirmed the lack of gown availability and the failure to follow EBP requirements. Additionally, the facility did not ensure proper hand hygiene during care activities. For Resident 11, a Medication Aide failed to perform hand hygiene between providing peri-care and administering medications. This was confirmed through observation and interview, indicating a breach in the facility's hand hygiene policy, which requires hand hygiene before moving from a soiled to a clean body site and after glove removal.
Deficient Transfer Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide the required information in the written notice of transfer for a resident who was transferred to the hospital. The resident, who had a primary diagnosis of dementia, was transferred on 8/16/2024. The notice of transfer lacked the resident's name, a specific medical reason for the transfer, and contact information for the state long-term care agency and the state long-term care ombudsman. This deficiency was confirmed during an interview with the Social Services Director, who acknowledged the omissions on the form.
Failure to Complete Significant Change MDS for Resident
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) for a resident who experienced a major decline in their health status. According to the facility's policy and the MDS RAI 3.0 Manual, a significant change in condition, such as a decline in Activities of Daily Living (ADLs) and unplanned weight loss, requires a comprehensive assessment. Resident 20, who was admitted with a diagnosis of dementia, showed a decline from requiring partial assistance to full assistance with oral hygiene and experienced significant weight loss between two quarterly MDS assessments. The MDS Coordinator confirmed that these changes in Resident 20's condition over the prior months warranted a significant change MDS, which was not completed. This oversight was identified during a survey, highlighting the facility's failure to adhere to the required assessment protocols as outlined by the Omnibus Budget Reconciliation Act (OBRA) regulations and the Resident Assessment Instrument (RAI) Manual.
Failure to Complete Discharge MDS for Hospitalized Resident
Penalty
Summary
The facility failed to complete and transmit a Discharge Minimum Data Set (MDS) for a resident upon hospitalization, as required by federal regulations. The resident, who had a primary diagnosis of dementia, was admitted to the facility and later transferred to a hospital for dehydration. Despite the hospitalization, a review of the facility's records showed that no Discharge MDS was completed within the mandated 14-day period following the resident's discharge to the hospital. This oversight was confirmed during an interview with the MDS Coordinator, who acknowledged that the discharge MDS should have been completed.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, which is a federally mandated comprehensive assessment of each resident's functional capabilities. For one resident with muscular dystrophy, the MDS did not accurately reflect the use of a Continuous Positive Airway Pressure (CPAP) device during the look-back period, despite records showing daily use. The MDS Coordinator confirmed that the resident had used the CPAP device during the specified period, and the assessment should have indicated this. Another resident's MDS inaccurately reported that they were not taking an anticoagulant, despite having an order for Xarelto for atrial fibrillation since 2018. The MDS Coordinator confirmed that the resident was indeed taking the anticoagulant, and this should have been documented in the MDS. These inaccuracies affected the facility's ability to provide accurate assessments for 2 of the 12 residents reviewed, with a total facility census of 47.
Incomplete Care Plan for Resident with Behavioral Symptoms
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 40, who was admitted with diagnoses of dementia, depression, and anxiety. The care plan lacked specific interventions to address the resident's behavioral symptoms, such as hitting or scratching self, pacing, rummaging, or making disruptive sounds, which were observed 1-3 days during a 7-day period. The care plan primarily focused on administering psychotropic and anti-anxiety medications, monitoring for side effects, and discussing medication use with the physician and family, but did not include non-pharmacological interventions tailored to the resident's specific behaviors. Interviews with facility staff revealed that Resident 40 exhibited behaviors such as yelling, refusing to lay in bed, and experiencing hallucinations, particularly in the evenings. Effective interventions identified by staff included offering snacks, toileting, providing one-on-one time, engaging in activities, and placing the resident in a recliner in common areas. However, these interventions were not documented in the care plan. The MDS Coordinator confirmed that the care plan was not comprehensive, as it did not address the specific behaviors or include the effective interventions used by staff.
Failure to Update Resident's ADLs Care Plan
Penalty
Summary
The facility failed to revise the activities of daily living (ADLs) care plan to reflect the current status of a resident. The facility's policy requires that care plans be revised as information about residents and their conditions change, at least quarterly. A review of the resident's quarterly Minimum Data Set (MDS) assessment revealed that the resident required moderate assistance with eating and was dependent for oral hygiene, toileting, dressing, and personal hygiene. However, the resident's care plan, last revised several months prior, indicated that the resident required extensive assistance with bathing, dressing, and personal hygiene, and only supervision with eating. An interview with the MDS Coordinator confirmed that the care plan was not updated to reflect the resident's current needs.
Failure to Implement Bowel Care Interventions
Penalty
Summary
The facility failed to implement interventions to prevent constipation for Resident 22, who had a primary diagnosis of dementia and severe cognitive impairment. The resident's records indicated prolonged periods without bowel movements, specifically from 8/19/2024 to 8/30/2024 and from 9/5/2024 to 9/9/2024. Despite having orders for various medications to treat constipation, including Senokot S, Miralax, Milk of Magnesia (MOM), Dulcolax suppository, and Fleet Oil enema, the resident did not receive these medications as needed. The Medication Administration Record (MAR) showed that the resident only received MOM on two occasions, with one instance marked as ineffective. Interviews with facility staff, including a Registered Nurse (RN), a Nurse Practitioner (NP) from hospice, and the Director of Nursing (DON), confirmed the lack of bowel movements and the absence of a bowel protocol. The DON acknowledged that the resident should have been given a PRN dose of Dulcolax when MOM was ineffective. The facility's night shift duty sheet provided some direction, but it was insufficient to address the resident's needs, as evidenced by the lack of documentation and action taken during the periods without bowel movements.
Failure to Implement Elopement Prevention for At-Risk Resident
Penalty
Summary
The facility failed to develop and implement interventions to prevent elopement for a resident identified as at-risk for wandering. The facility's policy on Wandering and Elopements, revised in March 2019, mandates that residents at risk of unsafe wandering should have a care plan with strategies and interventions to ensure their safety. However, a review of the resident's records revealed that despite being identified as at-risk on February 13, 2024, no care plan or interventions were in place prior to the resident's elopement on March 3, 2024. The resident was found outside the facility twice on the same day, indicating a lack of preventive measures. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the resident was recognized as at-risk for wandering and elopement, and interventions should have been developed and implemented earlier. The MDS Coordinator was in the process of obtaining consent to place a Wander guard when the resident eloped again. Additionally, the facility's documentation did not show evidence of 15-minute checks being conducted on the day of the elopement, which were supposed to be part of the resident's fall interventions. This lack of documentation and implementation of preventive measures contributed to the deficiency.
Failure to Include PAP Device Settings in Resident's Order
Penalty
Summary
The facility failed to ensure that a resident had a Positive Airway Pressure (PAP) device order that included the necessary settings. This deficiency was identified during a review of records and interviews, affecting one of two residents sampled for respiratory care. The facility's policy on CPAP/BiPAP support, last revised in March 2015, requires checking the physician's order to determine the pressure settings for the machine. However, the records for the resident, who was admitted with a primary diagnosis of muscular dystrophy, showed orders for a CPAP device without any specified settings. The resident's order summary and written orders from 2017 lacked the required pressure settings for the PAP device. Interviews with an LPN and the Director of Nursing confirmed the absence of these settings in the resident's orders. The deficiency was further highlighted by a review of the ResMed website, which states that a CPAP prescription should include a pressure setting determined by the prescribing physician based on a sleep study. This oversight in the resident's care plan indicates a failure to adhere to the facility's policy and standard practices for respiratory care.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for psychotropic medications as required for one resident. The facility's policy, revised in July 2022, mandates that residents on psychotropic medications should receive a GDR alongside non-pharmacological interventions unless clinically contraindicated. However, for Resident 16, who was on sertraline and trazodone, no such reduction was attempted despite the resident showing no symptoms of depression and no noted behaviors since December 2024. Resident 16's records indicated a Patient Health Questionnaire score of 0, suggesting no symptoms of depression, yet the resident continued to receive sertraline for major depressive disorder and trazodone for sleep. Gradual Dose Reduction Requests dated April and August 2024 showed no changes in medication orders, and there was no documentation from the physician indicating that a GDR was clinically contraindicated. The Director of Nursing confirmed the lack of evidence for contraindication and acknowledged that a GDR should have been attempted.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rushville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pioneer Manor Nursing Home | 11.9 mi | ★★★★★ | 4 | 0 |
| Gordon Countryside Care | 14.7 mi | ★★★★★ | 8 | 0 |
| Crest View Care Center | 28.7 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.