Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Eastern Star Home Of South Dakota, Inc during CMS and state inspections, most recent first.
A resident with advanced dementia fell out of a whirlpool chair when a CNA/bath aide raised the chair and tried to lock the wheels without using the required safety belt. The resident struck his head, had a forehead laceration, briefly lost consciousness, and was sent to the hospital where he received sutures.
Lack of GDR Documentation for Psychotropic Medications: Two residents receiving psychotropic meds, including antipsychotics and anxiolytics/antidepressants, had no attempted GDR or physician documentation showing why a GDR was clinically contraindicated. Their MDSs and care plans reflected ongoing psychotropic use for dementia-related symptoms and mood/behavior concerns, while pharmacy review forms repeatedly recommended continuing the same doses without documenting the rationale for not reducing the meds.
The facility failed to maintain the dishwasher wash cycle temperature at the required 120 degrees Fahrenheit, with recorded temperatures consistently below this threshold. Observations and interviews revealed missing sanitation checks and discrepancies in the facility's cleaning policy. Despite monthly servicing, the issue persisted, and the administrator was not informed of the low-temperature readings.
The facility failed to update care plans to reflect enhanced barrier precautions (EBP) for eight residents with catheters, indwelling feeding tubes, and open wounds. The MDS/infection preventionist was responsible for care plan updates but was unaware that some resident room doors lacked EBP signs. The facility's policy required notifying residents and representatives of care changes, but care plans were not revised to include EBP, resulting in a deficiency.
The facility failed to implement proper infection control measures for a resident with C-Diff and eight residents requiring Enhanced Barrier Precautions (EBP). A housekeeper did not use bleach to clean a C-Diff room, and staff were unaware of the need for EBP for residents with catheters, feeding tubes, and open wounds. Additionally, there was a lack of signage and inconsistent use of gowns by staff, contrary to facility policies.
Failure to Secure Resident in Whirlpool Chair
Penalty
Summary
A resident with advanced dementia and a BIMS score of 0 was being given a whirlpool bath when a CNA/bath aide did not use the required whirlpool chair safety belt. While the aide was behind the resident attempting to reposition the chair wheels to lock the brakes, she raised the chair slightly so the resident’s feet no longer touched the floor. The resident leaned forward and fell out of the whirlpool chair onto the floor, striking his head and causing a laceration to his forehead. After the fall, the resident was found lying on his left side on the floor with his left arm tucked underneath him. The aide was sitting on the floor next to him applying pressure to his head. The resident had a forehead laceration, was able to move all extremities, and had a neurological assessment and vital signs obtained. The aide stated the resident lost consciousness for less than one minute, denied nausea, and reported a headache. The on-call provider was notified, and emergency medical services were called and transported the resident to the hospital. Hospital records showed the resident received 12 sutures to the left frontal scalp. The resident had been admitted to the facility with dementia and severe cognitive impairment, and he later died at the facility. Interviews with staff confirmed that the whirlpool chair safety belt was not used during the bath and that the resident fell while the aide was adjusting the chair.
Lack of GDR Documentation for Psychotropic Medications
Penalty
Summary
The provider failed to ensure that two sampled residents who were receiving psychotropic medications had an attempted gradual dose reduction (GDR), or had documentation showing that a GDR was clinically contraindicated. For resident 28, the record showed diagnoses of dementia, depression, and traumatic brain dysfunction, with moderately impaired cognition, wandering, rejection of care, and psychotropic use that included an antidepressant and an antipsychotic. Her annual MDS indicated the antipsychotic had not had a GDR attempted in the past year, and there was no physician documentation supporting why a GDR was not appropriate. Resident 28’s care plan identified psychotropic medication use for depression and stated the goal was the lowest therapeutic dose, with a GDR review every six months. A pharmacy recommendation form initiated by the DON listed sertraline and olanzapine and asked for advice, but the consultant pharmacist recommended continuing the same dose and the physician agreed without documenting any clinical contraindication to a GDR. During interviews, the DON, administrator, and MDS coordinator agreed the physician had not provided a written rationale for maintaining the dose and not attempting a GDR. For resident 25, the record showed diagnoses of dementia and anxiety disorder, moderately impaired cognition, poor appetite, and psychotropic use that included an antianxiety medication and an antipsychotic. Her annual MDS indicated the antipsychotic had not had a GDR attempted in the past year and there was no physician documentation supporting why a GDR was clinically contraindicated. Her care plan stated psychotropic medications were being used for aggression, hallucinations, and delusional thinking, with a goal of the lowest dose and a GDR review every six months. Multiple pharmacy recommendation forms for Ativan and Risperidone were initiated by the DON, each recommending continuation of the same dose, but none included documentation of clinical contraindications to a GDR.
Dishwasher Temperature Noncompliance
Penalty
Summary
The provider failed to maintain the dishwasher wash cycle temperature at a minimum of 120 degrees Fahrenheit as required by the manufacturer's manual. Observations and interviews revealed that the dishwasher's wash cycle temperatures were consistently below the required threshold, with recorded temperatures ranging from 100 to 115 degrees Fahrenheit over several days. There were also numerous instances where wash, rinse, and chemical sanitation level checks were missing. The facility's dishwasher was serviced monthly by a vendor, but the issue persisted, and the administrator was not notified of the low-temperature readings. Interviews with dietary staff confirmed that the dishwasher's external thermometer readings matched those of a thermometer run through the dishwasher, both indicating temperatures below the required 120 degrees Fahrenheit. The dietary aide acknowledged that the wash temperature should be 120 degrees Fahrenheit. Despite the lack of gastrointestinal illness reported in the past three months, the administrator expected staff to report low-temperature readings, which did not occur. A review of the ECOLAB service report and the facility's cleaning policy revealed discrepancies in temperature requirements. The ECOLAB report noted a wash temperature of 100 degrees Fahrenheit and advised monitoring for compliance. The facility's policy inaccurately stated that the dishwasher, a chemical sanitizing machine, required temperatures between 90 and 110 degrees Fahrenheit, conflicting with the manufacturer's specification of a minimum of 120 degrees Fahrenheit.
Removal Plan
- Dietary staff were instructed to use paper plates and bowls and to use the three-compartment sink for cleaning and sanitizing of all utensils/pots/pans, etc. that are not disposable.
- Administrator met with Dietary staff and reviewed the policy and procedure on the use of the three-compartment sink as well as instructions located above the three-sink area.
- Administrator spoke with the representative from ECO Lab concerning this noncompliance. Recommendation to install a booster water heater to the current dishwasher unit.
- Administrator spoke with [Name] from [Name] Heating and Cooling and arranged for a service call to complete wiring for the installation of the booster water heater.
- [Name] Heating and Cooling presented to facility. Conversation was held with [Name] from [Name] Heating and Cooling and [Name] from ECO Lab via phone. [Name] from ECO Lab and [Name] from [Name] Heating and Cooling will be installing the booster water heater.
- Administrator completed and implemented new Dishwasher Temperature Policy and Low-Temperature Dishwasher Chart.
- Dietary Staff mandatory education will be held to review the Dishwasher Temperature Policy and Procedure as well as the Low-Temperature Dishwasher Chart.
- Daily audits to ensure compliance with the dishwasher temperature will be completed by this Administrator and will report findings to the QAPI Committee. Following continuous compliance, daily audits will change to weekly audits. The continuation of audits will be reviewed monthly during QAPI Committee meetings.
Failure to Update Care Plans with Enhanced Barrier Precautions
Penalty
Summary
The provider failed to ensure that resident care plans were revised to reflect the current enhanced barrier precautions (EBP) for eight of twenty sampled residents. This deficiency was identified through observation, interview, record review, and policy review. The Minimum Data Set (MDS)/infection preventionist (IP) was responsible for completing care plans on admission, quarterly, and whenever changes occurred. However, the care plans for residents with catheters, indwelling feeding tubes, and open wounds were not updated to include EBP, and there were no signs on the doors to inform staff of these precautions. The MDS/IP confirmed that she was unaware that some resident room doors were not marked with EBP signs, and the care plans had not been updated accordingly. The facility's care planning policy, dated 10/07/21, stated that the facility would notify the resident and/or resident representative in advance of care to be furnished, as well as changes to the plan of care. Despite this policy, the care plans for residents 1, 3, 6, 19, 21, 23, 27, and 28 were not revised to indicate the need for EBP, leading to the deficiency identified by the surveyors.
Inadequate Infection Control Measures for C-Diff and EBP
Penalty
Summary
The provider failed to ensure proper infection prevention and control measures for residents on precautions for Clostridium Difficile (C-Diff) and those requiring Enhanced Barrier Precautions (EBP). Specifically, a resident with C-Diff did not have their room cleaned with bleach as required. Instead, the housekeeper used Lysol, AF79, pH7 ultra, and pH7Q Dual for cleaning, none of which are appropriate for C-Diff precautions. The infection preventionist was unaware of the improper cleaning practices and the need for EBP for residents with catheters, indwelling feeding tubes, and open wounds. Additionally, the housekeeper had not received education on using bleach for cleaning rooms with C-Diff precautions. Furthermore, eight residents who required EBP due to conditions such as catheters, feeding tubes, and open wounds did not have appropriate signage on their doors, and staff did not consistently wear gowns when providing care. Interviews with residents and staff revealed that while gloves were used, gowns were not consistently worn, and there was a lack of signage indicating EBP. The facility's policies for managing C-Diff, indwelling catheter care, and tube feeding were not followed, contributing to the deficiencies observed.
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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 Redfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Redfield | 0.4 mi | ★★★★★ | 9 | 0 |
| Faulkton Senior Living | 31.9 mi | ★★★★★ | 3 | 0 |
| Good Samaritan Society Miller | 33.2 mi | ★★★★★ | 11 | 0 |
| Avantara Clark City | 38.4 mi | ★★★★★ | 7 | 0 |
| Avantara Huron | 38.6 mi | ★★★★★ | 14 | 1 |
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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.