Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Firesteel Healthcare Center during CMS and state inspections, most recent first.
Failure to timely report suspected abuse, neglect, and possible drug diversion. A resident alleged verbal abuse and neglect after two travel CNAs delayed call light response and refused to clean her after a transfer; the neglect allegation was validated, but the DON did not submit the required FRI to SD DOH. A second resident on hospice had morphine that appeared lighter in color, raising concern for tampering/diversion, and the DON acknowledged the state report was submitted late.
Staff failed to respond promptly to resident call lights for multiple residents, with repeated waits over 15 minutes and several waits over 30 minutes or more than an hour. Residents reported being left on the toilet, becoming incontinent, and seeing staff turn off call lights without helping. Staff said there were not enough walkie-talkies, and multiple employees were unaware of any set response-time expectation. The report also found unclear condom catheter care for a resident whose night catheter supplies were stored improperly and whose care instructions were not clearly detailed in the care plan or TAR.
A resident’s Dilaudid was received from the pharmacy and signed for by an LPN, but it was left unsecured in the med room instead of being double locked in the med cart. The next day, a CMA could not find the medication, and a facility-wide search confirmed it was missing. The DON stated the medication should have been secured in the cart, and the facility policy required Schedule II-V meds to be kept in separately locked, permanently affixed compartments.
Staff did not provide required supervision or follow care plan interventions for two residents, resulting in one resident with severe cognitive impairment and aspiration risk being left unsupervised in the dining room and sustaining multiple facial fractures after a fall, and another resident with Parkinson's disease falling during a transfer when only one CNA assisted with a sit-to-stand lift instead of the required two staff members.
A resident with a history of depression and prior suicidal ideations was admitted after a hospital stay with psychiatric recommendations for 24-hour supervision and increased monitoring. The facility did not implement increased supervision, update the care plan to reflect current suicidal risk, or notify the primary care provider after the resident expressed suicidal ideations. The resident was not seen again by mental health services after the initial evaluation, and staff failed to follow professional standards for suicide risk. The resident ultimately died by suicide, which was discovered by a CNA during routine rounds.
A resident with severe cognitive impairment and multiple neurological diagnoses was not consistently provided with a physician-ordered palm protector for contracture management. Despite documentation indicating the device was applied, observations showed the resident's hand was tightly contracted without the protector in place. Staff interviews revealed inconsistent application and lack of verification checks after transfers and meals, and no policy on following physician's orders was provided.
Staff failed to consistently perform hand hygiene and use appropriate PPE during resident care and meal assistance, did not properly implement or discontinue contact precautions, and neglected to clean shared equipment, all during a norovirus outbreak that affected many residents and resulted in hospitalizations.
A resident experienced a persistent infestation of flying ants in their room, reporting daily encounters and multiple bites, with visible evidence of ants and bites confirmed by staff and surveyors. Despite repeated cleaning, placement of ant bait, and pest control company visits, the problem continued for several weeks, indicating a failure to maintain an environment free of pests as required by facility policy.
Surveyors found that prepared foods were stored uncovered and ready-to-eat salad was placed below raw bacon in the walk-in cooler, creating a risk for cross-contamination. Egg salad sandwiches and bowls, considered potentially hazardous foods, were served to residents at temperatures above the required 41°F, with no documentation of temperature checks prior to service. Staff and management acknowledged these failures, which did not align with facility policies or professional food safety standards.
Persistent sewer and urine odors were present in multiple facility areas, including the therapy gym and a hallway near the nurse's station. A resident reported the sewer odor had been an ongoing issue, and staff confirmed repeated but unsuccessful attempts to resolve it. Another resident's room and the surrounding hallway had a strong urine smell due to incontinence and resistance to cleaning, with odors persisting despite deep cleaning efforts. These conditions resulted in an environment that was not safe, clean, or homelike.
Three residents' care plans were not updated to reflect their current needs, including a resident with PTSD whose trauma history and use of a foot cradle were omitted, a resident whose dietary preferences and use of a water bladder were not documented, and a resident whose care plan listed a resolved wound but failed to include current venous stasis ulcers and Unna boot treatment. Staff were often unaware of these omissions, and the facility did not provide a care plan policy during the survey.
Two residents and their representatives did not fully understand the binding arbitration agreement process during admission, with one agreement lacking clear documentation of acceptance or declination and both parties later reporting they were unaware that signing the agreement waived their right to legal action. Both residents were cognitively intact at the time, and the facility's process for explaining the agreement was found to be insufficient in ensuring informed consent.
The facility did not implement or document effective QAPI actions to address ongoing deficiencies in hand hygiene and PPE compliance, as repeated audits showed compliance rates below benchmarks and only staff education was used as a corrective measure. This inaction coincided with an outbreak of gastrointestinal illness affecting several residents and staff.
Two residents were allowed to self-administer nebulizer medications without required assessments, physician orders, or care plan documentation. Staff set up the treatments and left the residents unsupervised, contrary to facility policy, which mandates evaluation and authorization before permitting self-administration.
A resident identified as an elopement risk left the facility without staff knowledge when a door alarm was triggered. Staff failed to respond appropriately, as neither a CNA nor an RN checked outside the door after the alarm sounded. The resident was later found by a police officer and returned to the facility.
A resident in a LTC facility experienced a deficiency in safe transfer practices using a sit-to-stand lift. The resident, who required assistance from two staff members, was not properly secured during a transfer, leading to a fall. Staff interviews revealed inconsistencies in lift use and care plan adherence, while maintenance issues with the lifts, such as missing clips, were not promptly addressed.
A facility failed to follow prescribed renal and cardiac therapeutic diets during a supper service, affecting residents who required specific dietary accommodations. A cook served the same meal to all residents, overlooking the therapeutic diet spreadsheets due to inadequate training. The Diet Order Tally Record was outdated, and some residents had not signed risk/benefit forms to decline therapeutic diets.
A CNA took a photo of a resident's head injury without permission, violating privacy rights. The resident, who was severely cognitively impaired and in hospice care, had fallen and sustained a head injury. The CNA, concerned about the resident's condition, took the photo but did not share it. The CNA was agency staff and had completed HIPAA training.
The facility failed to monitor neurological changes in five residents after falls. A resident on hospice care and another with cardiac issues did not receive required neurological evaluations post-fall. The DON acknowledged the lapse in following the facility's policy, which mandates evaluations for 72 hours after an unwitnessed fall or head injury.
A resident with cognitive impairment spilled coffee on herself due to the facility's failure to conduct a hot liquid assessment at admission. The facility also lacked consistent temperature monitoring of hot beverages, as required by policy, leading to a deficiency in ensuring resident safety.
A resident with moderate cognitive impairment was readmitted to a facility with a clostridium difficile diagnosis and an order for Vancomycin. The admitting team incorrectly entered the antibiotic order as unsupervised medication administration, leading to the resident missing 16 doses. Despite this, nurses charted no adverse side effects. The error was discovered after the resident was readmitted to the hospital for hyponatremia and hyperglycemia. Staff interviews revealed a lack of awareness and communication regarding the medication order error.
A resident fell from a mechanical lift due to the use of an incorrectly sized sling, resulting in a hip fracture and hospitalization. The resident, who was cognitively intact and had multiple health conditions, became unbalanced during the transfer. Staff interviews revealed that the sling used was too large, and the RN confirmed it was placed incorrectly, leading to the fall.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights for several residents. Observations and interviews revealed that residents experienced long wait times for assistance, particularly those requiring mechanical lifts for transfers. Staff shortages and the lack of specific policies for call light response times contributed to the inconsistency in care delivery.
A resident with multiple health conditions, including low potassium levels, did not receive prescribed doses of folic acid and potassium chloride after being admitted to the facility. The medication errors were due to issues with the electronic medical record system and lack of proper double-checking and confirmation of orders, leading to the resident's hospitalization for low potassium levels and other complications.
The provider failed to ensure that two residents who smoked were assessed for safety. One resident, at risk for elopement, was allowed to go outside independently due to a miscommunication, and another resident was not aware of any designated smoking area and had not been assessed for smoking safety. The facility's smoking safety policies were not followed.
Failure to Timely Report Abuse, Neglect, and Possible Drug Diversion
Penalty
Summary
The facility failed to report suspected abuse and neglect to the South Dakota Department of Health within the required time frame for two residents who had reportable incidents. One resident submitted an email complaint alleging verbal abuse and neglect by two travel CNAs after being told she should have better time management when using the call light and after staff refused to clean her bare buttocks when assisting her from the toilet to her wheelchair. The DON responded to the resident by email, but no facility reported incident was submitted to the state within the required time frame, and the resident later died before an interview could be completed. The investigation later confirmed that the allegation of verbal abuse was not substantiated by three staff witnesses, but the allegation of neglect was validated because the resident experienced a long wait for assistance after activating the call light. The resident required three staff for transfers, which delayed care because two CNAs were assisting another resident and needed a third staff member to help. The DON acknowledged that the incident was reportable and that the initial and final reports were not submitted as required, and there was no documentation that education was completed for all staff regarding the incident. A second reportable incident involved a resident on hospice care whose morphine appeared lighter in color than expected, raising concern for possible tampering or diversion. The discrepancy was first noted by the DON and later investigated by an RN, who found the medication looked more like water than morphine when drawn into a syringe. Staff on the unit gave mixed accounts of the medication’s color, and the DON acknowledged the report to the state was submitted late because she had forgotten to begin the investigation when the concern was first raised.
Delayed Call Light Response and Unclear Condom Catheter Care
Penalty
Summary
The facility failed to ensure staff responded promptly to resident call lights for four sampled residents who reported long waits for assistance. One cognitively intact resident stated that when he first arrived he needed more help because of weakness, but his call lights were not answered quickly and he sometimes became incontinent before staff arrived, which embarrassed and upset him. His call light response report showed multiple waits over 15 minutes, several over 30 minutes, and one over 53 minutes after he moved rooms. Another cognitively intact resident submitted a complaint stating she waited nearly an hour after pushing her call light to get off the toilet, and travel CNAs entered her room, told her she needed better time management, and were unable to assist because they were delivering meal trays. The grievance record showed her call light was not answered for 57 minutes, and her response report documented multiple waits over 15 and 30 minutes, including one over 57 minutes. A third resident reported that he put on his call light for restroom assistance, staff came in, turned it off, and left without helping him, and he waited over an hour before becoming incontinent of urine. The facility’s investigation validated neglect had occurred, and the resident’s call light response report showed multiple waits over 15 minutes. A fourth cognitively intact resident reported that call light response times had worsened over the past few months, that she had waited more than an hour at times, and that some staff would turn off the call light and leave without assisting her. She also stated that staffing issues and a lack of walkie-talkies made it harder for staff to know when call lights were activated. Her call light response report showed 28 waits over 15 minutes and one wait of 1 hour and 16 minutes. Staff interviews confirmed there were not enough walkie-talkies for all scheduled staff at times, so some staff had to check the nurse station computer monitor to see activated call lights. Multiple staff members stated they were not aware of a facility expectation for call light response times, while leadership stated the expectation was under 15 minutes but there was no policy or designated response time. The administrator confirmed the facility did not have a policy or procedure for call light response times. The report also described a separate deficiency involving resident 5’s condom catheter care: he used a condom catheter at night, but the nursing staff did not clearly carry out or communicate the expected care, and his catheter tubing and bag were found stored inappropriately in his bathroom with a strong urine odor and no date showing when they were last replaced. Staff and leadership stated the care plan and TAR did not contain enough detail for new staff to know what was expected.
Controlled medication was left unsecured and later found missing
Penalty
Summary
Pharmaceutical services failed to ensure a controlled medication was secured for one resident when Dilaudid 2 mg, 60 tablets, received from the pharmacy on 3/20/26, was not accounted for the following day. The medication was signed for by an LPN and taken to the Hall 400 medication room, but it was not properly signed or secured in the locked medication cart. On 3/21/26, a CMA could not find the medication, and the facility confirmed it was missing after a facility-wide search. The pharmacy confirmed the medication had been sent to the facility and had not been returned. During interview, the DON stated she was notified of the missing medication on 3/21/26 and that staff completed a facility-wide search. She reported that staff involved in signing in and failing to secure the controlled medication were terminated. The DON acknowledged the medication should have been double locked in the medication cart and stated she did not review camera footage. The administrator later stated the facility camera footage only went back 30 days and any footage of the incident was no longer available. The facility's Controlled Medication Storage policy stated Schedule II-V medications must be maintained in separately locked, permanently affixed compartments.
Failure to Provide Supervision and Follow Care Plans Leads to Resident Falls
Penalty
Summary
Staff failed to provide adequate supervision and accident prevention interventions as outlined in residents' care plans, resulting in two separate incidents involving falls. In one case, a resident with severe cognitive impairment, repeated falls, progressive supranuclear ophthalmoplegia, dementia, and a history of aspiration risk was left unsupervised in the dining room. Despite multiple prior falls in the same location and care plan interventions specifying that the resident should not be left alone, staff left the resident unattended while assisting others. The resident was subsequently found face down on the floor with significant facial injuries, including multiple facial fractures and a comminuted nasal bone fracture. The care plan had been updated after previous incidents to require supervision in the dining room, but this intervention was not followed at the time of the fall. Interviews with staff revealed that the staff member assigned to supervise the dining room did not remain with the resident as required, citing competing care needs elsewhere in the facility. The daily staffing assignment sheet identified who was responsible for dining room supervision, but staff often did not adhere to these assignments. The medication aide and nurse confirmed that the resident should not have been left unsupervised, especially given his swallowing difficulties and risk for aspiration. The director of nursing acknowledged that the care plan intervention for dining room supervision was not followed at the time of the incident. In a separate incident, another resident with Parkinson's disease, weakness, and abnormal gait was being transferred using a sit-to-stand mechanical lift. The care plan specified that two staff members were required for transfers with this device due to the resident's instability. However, only one CNA performed the transfer, and the resident's hands slipped from the handlebars, resulting in a fall to the floor. The CNA was unaware of the updated care plan requirement for two-person assistance. Both the nurse and the CNA confirmed that the care plan was not followed, and the director of nursing agreed that this failure placed the resident's safety at risk.
Failure to Provide Necessary Behavioral Health Services Resulting in Resident Suicide
Penalty
Summary
A facility failed to provide necessary behavioral health care and services to a resident with a diagnosed serious mental illness, resulting in the resident's suicide. The resident had a history of depression, prior suicidal ideations, and was admitted to the facility following a hospital stay where psychiatry had recommended 24-hour supervision, psychiatric medication management, and increased monitoring due to high suicide risk. Despite these recommendations, the facility did not implement increased supervision or update the resident's care plan to reflect active suicidal ideations and necessary interventions. The resident's care plan only indicated a history of suicidal ideations, not current risk, and staff were not instructed to monitor the resident more closely or search for means of self-harm in the resident's room. Documentation in the resident's medical record showed that after expressing suicidal ideations to a family member, there was no follow-up assessment or increased monitoring by staff. The primary care provider was not notified of the resident's suicidal statements, and there was no evidence of ongoing psychiatric follow-up or consistent behavioral health services after the initial mental health visit. The contracted mental health service did not have a routine schedule for seeing residents, and the resident was not seen again after the initial evaluation. Staff interviews revealed a lack of awareness regarding the seriousness of the resident's suicidal ideations and a failure to communicate critical information among the care team. The facility's own reference materials and professional standards outlined the need for close observation, psychiatric referral, and crisis intervention for residents with depression and suicidal ideations. However, these standards were not followed, as evidenced by the absence of increased supervision, lack of care plan updates, and failure to notify the primary care provider or implement safety interventions. The resident ultimately committed suicide in his room, and the incident was discovered by a CNA during routine rounds.
Failure to Ensure Physician-Ordered Palm Protector Applied for Contracture Management
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple complex diagnoses, including ataxia, stiff-man syndrome, dementia, mood disorder, weakness, repeated falls, malignant neoplasm of the brain, and epilepsy, was not provided with a palm protector as ordered by the physician for contracture management of his right hand. Observations on two consecutive days revealed the resident's right hand was tightly curled with fingers digging into the palm, and no palm protector was in place. The resident stated he only wore the device when working, and a newly hired CNA reported never seeing the resident wear the palm protector. Documentation in the electronic medical record indicated the device was applied, but direct observation contradicted this. Further interviews with staff revealed that while there were instructions and documentation processes in place for the application of the palm protector, there were no scheduled verification checks after transfers or meals to ensure the device was reapplied as required. The facility was unable to provide a policy regarding following physician's orders during the survey. These actions and inactions led to the failure to ensure the resident consistently received the prescribed contracture management intervention.
Failure to Follow Infection Control Practices During Norovirus Outbreak
Penalty
Summary
Staff at the facility failed to adhere to proper infection prevention and control practices, particularly regarding hand hygiene and the use of personal protective equipment (PPE). During multiple observations, staff members did not perform hand hygiene at critical points, such as after removing gloves, after touching potentially contaminated surfaces, or before assisting residents with eating. For example, two CNAs were observed changing a resident's soiled brief, touching various items in the resident's environment with contaminated gloves, and then failing to perform hand hygiene after glove removal. Additionally, staff were seen assisting residents with eating and handling food items without sanitizing their hands, even after touching their own hair or after coughing into their hands. The facility also failed to ensure proper implementation and discontinuation of contact precautions for residents with gastrointestinal (GI) symptoms. Staff did not consistently wear required PPE, such as gowns and gloves, when providing care to residents on contact precautions. In one instance, staff were unaware of which resident in a shared room was on contact precautions and did not follow posted signage or use appropriate PPE. Equipment such as full body lifts was not cleaned between uses, and contact precaution signage and supplies were not promptly removed or updated when precautions were discontinued. These lapses in infection control practices occurred during a facility-wide norovirus outbreak, which affected at least 45 residents with confirmed or suspected GI symptoms. The outbreak led to hospitalizations, including one resident who was admitted to the ICU. The facility's own policies required regular staff training, proper hand hygiene, and adherence to transmission-based precautions, but these were not consistently followed as evidenced by direct observations, interviews, and record reviews.
Failure to Ensure Effective Pest Control for Flying Ants
Penalty
Summary
The facility failed to ensure effective pest control for flying ants in the room of one resident who repeatedly reported and demonstrated the presence of flying ants and ant bites. The resident stated that he experienced a daily problem with flying ants, killing 30 to 40 each day, and reported being bitten multiple times, with visible red marks on his back. Observations confirmed the presence of dead and live flying ants on the resident's nightstand, bed, and window screen over several days. The resident also reported that the problem had persisted for several weeks, and maintenance staff believed the ants were entering from behind the heater below the window. Documentation and interviews revealed that the facility was aware of the issue as early as 4/11/25, when a work order was created in the maintenance system. Staff responded by deep cleaning the room, placing ant bait, and spraying ant killer outside the affected area. Despite these actions, the flying ant problem continued, as evidenced by ongoing resident complaints and direct observations of ants in the room. The pest control company had provided regular monthly services and an extra visit in March, but there was no documentation of additional targeted pest control interventions after the problem was reported in April. The facility's pest control policy required prompt reporting and additional pest control visits when a problem was detected. However, records showed that after the initial reports and interventions, the flying ant infestation persisted in the resident's room, with no evidence of further pest control company involvement or effective resolution. The ongoing presence of flying ants and the resident's continued exposure to bites indicated a failure to maintain an environment free of pests as required by facility policy.
Improper Food Storage and Temperature Control in Kitchen
Penalty
Summary
Surveyors identified multiple failures in food safety practices within the facility's kitchen, specifically related to the storage, preparation, and serving of food. Observations revealed that prepared foods, such as individual servings of chocolate pudding and uncooked pizzas, were stored uncovered in the walk-in cooler, leaving them exposed to air. Additionally, a ready-to-eat salad was stored on the bottom shelf directly underneath a cardboard box of raw bacon strips, which had water on top, creating a risk for cross-contamination. The salad was later served to residents during a meal service. Staff interviews confirmed that the salad had been prepared that day and would be served, and both staff and management acknowledged the improper storage and potential for cross-contamination. Further deficiencies were noted in the handling of potentially hazardous foods (PHF/TCS), specifically egg salad sandwiches and bowls prepared with hard-boiled eggs and mayonnaise. These items were prepared in advance, stored in the walk-in cooler, and served to residents during meal service. Temperature checks conducted by the regional dietitian revealed that the egg salad items were held at temperatures ranging from 50.4 to 53.4 degrees Fahrenheit, which is above the required maximum of 41 degrees Fahrenheit for safe cold holding of PHF/TCS foods. There was no documentation of food temperatures being taken prior to meal service to ensure compliance with food safety standards. Review of facility policies confirmed that raw meats and eggs should not be stored above ready-to-eat foods and that PHF/TCS foods must be cooled and held at or below 41 degrees Fahrenheit. The posted Safe Refrigerator Storage chart in the walk-in cooler was not followed, as evidenced by the improper storage of raw and ready-to-eat foods. Staff and management interviews consistently acknowledged the observed deficiencies and agreed that the practices did not meet the facility's own policies or professional standards for food safety.
Failure to Maintain Odor-Free, Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment free from foul odors in multiple areas, including the physical therapy gym, the nurse's desk outside the therapy gym, the rehab dining room, and the 200-hallway near the nurse's station. Staff and residents reported a persistent sewer odor, particularly near the therapy gym, which was confirmed by both observation and interviews. Maintenance records showed repeated work orders addressing the sewer smell, including smoke tests and plumbing repairs, but the odor continued to be present and noticeable to residents and staff. One resident reported the issue had persisted for years and had communicated concerns to the administrator multiple times, but the problem was not fully resolved. Additionally, a strong urine odor was observed in a resident's room on the 200-hallway and was noticeable down the hall near the nurse's station. The resident was found lying on his bed in wet clothing, with an empty urinal nearby, and did not perceive the odor himself. Staff interviews indicated that the resident often missed the urinal, resulting in urine on the floor and other surfaces, and that he was resistant to having his room cleaned or his linens changed. Housekeeping staff attempted to coordinate cleaning with the resident's bath days, but reported limited cooperation from nursing staff in addressing persistent odor issues. Despite deep cleaning efforts and the use of disinfectant cleaners, the urine odor in the resident's room and the surrounding hallway persisted, sometimes masked by air fresheners. Housekeeping policies required daily damp mopping and thorough cleaning, but the ongoing presence of strong odors indicated that these measures were not effective in eliminating the problem. The facility's failure to address and resolve these odor issues resulted in an environment that was not safe, clean, comfortable, or homelike for residents.
Failure to Update Care Plans for Resident Needs and Interventions
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated to reflect the current needs and preferences of three residents. For one resident with major depressive disorder and PTSD, the care plan did not include her PTSD diagnosis or interventions to prevent re-traumatization, nor did it mention the use of a foot cradle that had been implemented months prior. Staff members, including CNAs and the MDS coordinator, were unaware of the resident's trauma history, triggers, or the specialized equipment in use, indicating a lack of communication and documentation regarding her psychosocial and physical care needs. Another resident's care plan did not reflect her preference to skip breakfast or her use of a hiking water bladder for fluid intake while in bed, despite staff being aware of these preferences and accommodations. The omission of these details from the care plan meant that her individualized dietary and hydration needs were not formally documented for all staff to follow. The intake team and MDS coordinator typically managed care plan updates, but these specific preferences and equipment were not included. A third resident's care plan listed a resolved surgical wound on the neck but failed to document current venous stasis wounds on both lower legs and the use of Unna boots for treatment. Nursing staff confirmed the presence of these wounds and the ongoing treatment, but the care plan was not updated to reflect the current skin integrity issues or interventions. The facility did not provide a care plan policy during the survey, and staff interviews revealed inconsistent practices regarding the inclusion of wound treatments and specialized equipment in care plans.
Failure to Ensure Informed Consent for Binding Arbitration Agreements
Penalty
Summary
The provider failed to ensure that residents or their representatives fully understood the binding arbitration agreement process during admission. For two of three sampled residents, documentation and interviews revealed that the process for informing and obtaining consent regarding the arbitration agreement was insufficient. One resident's wife signed the agreement but later stated she did not recall what the agreement entailed or that it involved waiving the right to legal litigation in court. She reported feeling overwhelmed during the admission process and did not remember a thorough explanation of the arbitration agreement, indicating she would not have signed had she understood its implications. The resident himself could not recall the agreement or its significance, and expressed frustration upon learning about the waiver of legal rights. Record review showed inconsistencies in the documentation of consent. For one resident, the arbitration agreement form lacked a checkmark indicating acceptance or declination, while another resident's form included a marked acceptance. The facility's social services director acknowledged that the parent company had recently revised the form to include explicit options for acceptance or declination to improve clarity. Despite these changes, interviews indicated that the explanation of the agreement may not have been sufficiently detailed or comprehensible for residents and their representatives at the time of signing. Both residents involved were assessed as cognitively intact according to their Brief Interview for Mental Status (BIMS) scores at the time of admission and subsequent assessments. The facility's process involved the social services director meeting with residents and representatives to review admission paperwork, including the arbitration agreement, and explaining that participation was optional. However, the lack of clear documentation and the residents' and representatives' lack of understanding demonstrated a failure to ensure informed consent regarding the binding arbitration agreement.
Failure to Implement Effective QAPI Actions for Infection Control Deficiencies
Penalty
Summary
The facility failed to identify, implement, and document effective quality assurance and performance improvement (QAPI) plans to address ongoing infection control deficiencies related to hand hygiene and personal protective equipment (PPE) compliance. Over a three-month period, audits consistently showed that staff compliance with hand hygiene and PPE protocols remained below the facility's established benchmarks. Despite monthly QAPI meetings and the identification of these issues, the only action taken was to continue staff education, with no additional interventions or strategies documented to address the persistent non-compliance. Observations and interviews during the survey period revealed that these deficiencies potentially contributed to an outbreak of gastrointestinal illness affecting multiple residents and staff. QAPI records showed inconsistent benchmarks for compliance and repeated documentation of the same issues and corrective actions across several months, with little to no change in outcomes. Meeting notes often left outcome sections blank or repeated previous entries, indicating a lack of effective follow-up or adjustment to the plan of correction.
Failure to Assess and Authorize Self-Administration of Nebulizer Medications
Penalty
Summary
The provider failed to ensure that two residents were properly assessed for their ability to safely self-administer nebulizer medications, as required by facility policy. In the case of one resident with moderate cognitive impairment (BIMS score of 12), staff set up the nebulizer medication and left the resident to self-administer the treatment without remaining in the room or directly supervising the process. There was no physician's order authorizing self-administration, no assessment documenting the resident's capability to self-administer, and the care plan did not reflect self-administration of medications. Staff confirmed that these required steps had not been completed. Similarly, another resident, who was cognitively intact (BIMS score of 15), was observed independently inhaling a nebulizer treatment without staff present. Although the resident had received initial education and supervision, staff subsequently left him alone to complete the treatments. There were no physician's orders, assessments, or care plan documentation supporting his ability to self-administer the nebulizer medication. The facility's policy requires a self-medication evaluation, a physician's order, and care plan updates before allowing residents to self-administer medications, none of which were completed for these residents.
Resident Elopement Due to Inadequate Response to Door Alarm
Penalty
Summary
A resident identified as an elopement risk on admission was not accounted for when a door alarm activated. The incident occurred when the resident left the facility without staff knowledge, and the door alarm was triggered. The resident was later found by a city policeman and a maintenance supervisor and was brought back to the facility. At the time of the incident, the resident had a Wander Guard in place, which was supposed to activate the door alarm, and her medical record indicated severe cognitive impairment. The facility's staff failed to respond appropriately to the door alarm. A certified nursing assistant (CNA) noticed the alarm and the blinking red light above the emergency exit doors but did not open the door or look out the window to check if someone had left. The CNA reported the alarm to a registered nurse (RN), who also failed to visually check outside the door after silencing the alarm. The RN's employment was terminated following the incident. The facility had video surveillance cameras on some entrance/exit doors, but the door alarm panel for the 400 hall, where the incident occurred, was not yet installed. The executive director confirmed that neither the CNA nor the RN visually checked outside the door to see if someone had left the facility. The resident was eventually found outside by a police officer, who was informed by the maintenance supervisor that the resident belonged to the facility.
Deficiency in Safe Transfer Practices Using Sit-to-Stand Lifts
Penalty
Summary
The deficiency involved a failure to ensure the safety of a resident during transfers using a sit-to-stand lift. The resident, who was cognitively intact and weighed between 366 and 375 pounds, required assistance from two staff members for transfers. However, during a transfer from the commode to a recliner, the safety strap of the sling was not adjusted, and the resident had to be lowered to the floor. The incident occurred when a CNA attempted to transfer the resident alone, without fastening the leg strap or ensuring the mid-body lift sling strap was tightened. Interviews with staff revealed inconsistencies in the use of mechanical lifts, with some staff not adhering to the care plan or special instructions for each resident. The care plan for the resident in question was not updated to reflect changes in transfer methods, and there was confusion among staff regarding which lift and sling to use. Additionally, some lifts were reported to lower residents unexpectedly, and several lifts were found to be missing necessary clips for safe operation. The facility's maintenance procedures were also called into question, as missing parts on the lifts were not reported or addressed in a timely manner. The maintenance supervisor was unaware of the missing clips and had not been notified of any mechanical issues through the facility's electronic work order system. Despite monthly inspections, the deficiencies in the lifts' condition and the lack of proper staff notification contributed to the unsafe transfer conditions for the resident.
Failure to Follow Therapeutic Diets
Penalty
Summary
The facility failed to adhere to the planned menu for residents on renal and cardiac therapeutic diets, as observed during a supper service. A resident, who was prescribed a renal diet due to dialysis treatments, did not receive the correct foods as per her dietary requirements. The cook, responsible for meal preparation, served the same meal to all residents, disregarding the specific menu items for therapeutic diets. The cook admitted to overlooking the therapeutic diet spreadsheets and attributed this oversight to inadequate training and support during his initial days at the facility. Further investigation revealed that the Diet Order Tally Record, which should guide the preparation of meals for different diet types, had not been updated since mid-December, despite the Food and Nutrition Services Director's claim of daily updates. Additionally, some residents had signed risk/benefit forms to decline therapeutic diets, but others, including those affected by the oversight, had not. The facility's policy on therapeutic diets mandates that these diets be prescribed by a physician and regularly reviewed, but the failure to follow these procedures led to the deficiency.
Privacy Violation Due to Unauthorized Photo
Penalty
Summary
A certified nursing assistant (CNA) took a photo of a resident's head injury without permission, violating the resident's right to privacy. The incident occurred after the resident had fallen and sustained a head injury, which was assessed by a registered nurse (RN). The CNA, who was concerned that the resident should have been sent to the hospital, took the photo but did not share it with anyone. The CNA was an agency staff member and had previously signed the Health Insurance Portability and Accountability Act (HIPAA) corporate training. The resident involved in the incident was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 0, and had been admitted to hospice for end-of-life care. The resident's medical conditions included moderate protein-calorie malnutrition, anxiety disorder, major depressive disorder, and a urinary tract infection. The resident required assistance from two staff members for transfers between surfaces. The CNA's action of taking a photo without permission led to a privacy violation, as there were no identifying marks in the photo, and the photo was not shared with others.
Failure to Monitor Neurological Changes Post-Fall
Penalty
Summary
The provider failed to adequately monitor five residents for neurological changes after they experienced falls. Resident 2, who was severely cognitively impaired and on hospice care, had an unwitnessed fall and was found with a lump and abrasions on her head and lip. Although a registered nurse completed an initial assessment, the required neurological evaluations were not conducted at the designated times. Similarly, Resident 3, who was cognitively intact and had a history of cardiac issues, fell in the hallway, and while an initial assessment was performed, the subsequent neurological evaluations were not completed as required. Residents 4, 5, and 6 also did not receive the necessary neurological evaluations following their falls. The Director of Nursing (DON) acknowledged that RN I, who was responsible for the initial assessments, had not completed the neurological evaluations as per the facility's policy. The DON had previously educated the staff on the importance of these evaluations but had not provided any new training since October. The facility's policy mandates neurological evaluations for 72 hours following an unwitnessed fall or head injury, with specific intervals for assessments. The failure to adhere to this policy resulted in a deficiency in monitoring the residents' neurological status post-fall.
Failure to Conduct Hot Liquid Assessment and Monitor Beverage Temperatures
Penalty
Summary
The facility failed to ensure resident safety by not completing a hot liquid assessment at the time of admission for a resident who spilled coffee on herself. The resident, who was moderately to severely cognitively impaired due to Alzheimer's/Dementia, did not sustain any injury from the incident. However, the lack of a hot liquid assessment at admission was a significant oversight, as the resident's baseline care plan indicated impaired cognitive function. The incident revealed that the facility did not have a consistent process for assessing the risk of hot liquid spills for new admissions. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) confirmed that hot liquid assessments were only conducted if a problem arose, such as a spill. Additionally, the facility's temperature log sheets for coffee and hot water were inconsistent, with some logs missing or showing conflicting temperatures, indicating a lack of proper monitoring and documentation. Observations in the dining hall showed that hot beverages were being served without verified temperature checks, as there were no temperature log sheets near the coffee makers. The facility's policy required that hot beverage temperatures not exceed 150 degrees Fahrenheit at resident contact, but this was not consistently enforced. The failure to adhere to these procedures and policies contributed to the deficiency in ensuring a safe environment for residents.
Failure to Administer Physician-Ordered Antibiotic Treatment
Penalty
Summary
The provider failed to administer physician-ordered antibiotic treatment and monitoring for a resident who had an infection and was readmitted to the hospital. The resident, who had moderate cognitive impairment, was readmitted to the facility with a diagnosis of clostridium difficile and had an order for Vancomycin HCI Oral Suspension. However, upon re-admission, the admitting team incorrectly entered the antibiotic order into the electronic medical record (EMR) system as unsupervised medication administration, indicating the resident was to self-administer the medication unsupervised. As a result of this error, the resident missed 16 scheduled doses of Vancomycin, which were incorrectly marked as unsupervised self-administration on the medication administration record (MAR). Despite the missed doses, nurses charted that the resident did not have any adverse side effects from the medication on several occasions. The resident was eventually readmitted to the hospital for hyponatremia and hyperglycemia, along with loose stools, after the error was discovered and corrected. Interviews with staff revealed a lack of awareness and communication regarding the incorrect medication order. The admission team, responsible for transcribing and double-checking medication orders, failed to identify the error. Additionally, the certified medication aides (CMAs) and nurses did not question the green box on the MAR, which indicated the medication had already been given. The director of nursing services acknowledged the communication gap and confirmed that the resident had not received the prescribed doses of Vancomycin.
Resident Fall Due to Incorrect Sling Size
Penalty
Summary
A resident experienced a fall from a full mechanical lift, which resulted in hospitalization for a right hip fracture. The incident occurred when the resident was being transferred using a sling that was too large, causing her to become unbalanced and slide out of the sling onto the floor. At the time of the fall, the resident was cognitively intact and had multiple diagnoses, including cardiomyopathy and atrial fibrillation. The resident's care plan was not followed correctly, as the incorrect sling size was used during the transfer. Interviews with staff revealed that the sling used was not appropriately sized for the resident, and the shoulder straps were longer than needed. The CNA involved in the transfer admitted that the sling used was the one available with the lift, regardless of size. The RN on duty confirmed that the sling was placed incorrectly, contributing to the fall. The facility's fall policy required specific actions and notifications following a fall, but the incorrect use of equipment led to the incident.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The report identifies a deficiency in the facility's ability to provide adequate staffing to meet the needs of residents, particularly in responding promptly to call lights. Observations and interviews revealed that residents experienced significant delays in receiving assistance, with some waiting over 30 minutes for staff to respond to call lights. This issue was prevalent across multiple residents, including those who required mechanical lifts for transfers, which further complicated timely assistance due to the limited availability of lifts and staff. Interviews with residents and their family members highlighted the impact of these delays, with reports of residents waiting excessively long times for assistance with transfers and toileting. Some residents expressed feelings of frustration and embarrassment due to incontinence incidents resulting from the delays. The call light audit reports corroborated these accounts, showing numerous instances of extended wait times, some exceeding 45 minutes. Staff interviews revealed that the facility was often understaffed, with CNAs responsible for a large number of residents, making it challenging to provide timely care. The facility lacked specific policies for call light response times and lift usage, contributing to the inconsistency in care delivery. Despite conducting call light audits, the facility's administration did not recognize the extent of the problem, and there was no established protocol for addressing the delays in call light responses.
Failure to Administer Medications as Ordered
Penalty
Summary
The provider failed to correctly administer medications as ordered for a resident who required hospitalization. The resident was admitted to the facility with diagnoses including hypopotassemia, anemia, acute kidney injury, chronic kidney disease stage III, hypertension, and malignant neoplasm of the bladder. Upon admission, the resident had a potassium level of 2.8, which is below the normal range. The hospital discharge orders included medications such as folic acid, potassium chloride, sodium bicarbonate, and urea-lactic acid cream. However, the resident did not receive the prescribed doses of folic acid and potassium chloride on multiple occasions from the time of admission until the resident was hospitalized again for low potassium levels and other complications. The facility's medication administration record (MAR) revealed that the resident missed doses of folic acid and potassium chloride. Progress notes indicated that the pharmacy had reviewed the admitting orders, but the medications were not administered as required. The resident's potassium level remained critically low, leading to a transfer to the emergency department and subsequent admission to the ICU for intravenous potassium administration. Interviews with the facility staff, including the executive director, registered nurses, and licensed practical nurses, confirmed that the medication orders were not properly entered, double-checked, or confirmed in the electronic medical record (EMR) system, leading to the missed doses. The director of nursing and the minimum data set coordinator confirmed that the resident had not received the medications as ordered. They acknowledged that the EMR integration and the pending confirmation notice for new orders contributed to the medication errors. A medication error form was completed, and the resident's primary care provider was updated on the situation. The facility had an emergency medication supply (E-kit) that could have been used, but it was not utilized in this case. The staff interviews and record reviews highlighted the deficiencies in the medication administration process, leading to the resident's hospitalization.
Failure to Assess Smoking Safety for Residents
Penalty
Summary
The provider failed to ensure that two residents who smoked were assessed for safety. Resident 1, who was at risk for elopement and wore a Wanderguard, was allowed to go outside independently by a receptionist who misinterpreted instructions from the DON. Resident 1 had a history of asking for cigarettes and became upset when staff refused to take him outside to smoke. A smoking safety assessment for Resident 1 was only completed after he left the property without staff knowledge to smoke a cigarette. Resident 2, who smoked cigarettes, was not aware of any designated smoking area and had not been assessed for smoking safety. She relied on a friend to take her outside to smoke and did not receive assistance from staff. Despite being aware that both residents smoked, the DON admitted that smoking safety assessments were not routinely completed for residents who smoked. The facility's policy required smoking safety evaluations on admission and with changes in condition, but these were not followed. The facility also had a Smoke-Free Center Policy Acknowledgement form signed by both residents on admission, but this policy was not effectively enforced or communicated to staff and residents. The provider's updated Resident Smoking Safety policy outlined specific procedures for smoking safety evaluations and designated smoking areas, but these were not adhered to, leading to the deficiency.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mitchell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avera Brady Health And Rehab | 2 mi | ★★★★★ | 3 | 0 |
| Avera Bormann Manor | 21.9 mi | ★★★★★ | 9 | 0 |
| Prairie View Healthcare Center | 26.8 mi | ★★★★★ | 2 | 0 |
| Diamond Care Center | 27.6 mi | ★★★★★ | 13 | 0 |
| Good Samaritan Society Corsica | 28.2 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.