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 Flandreau Santee Sioux Tribe Care Center during CMS and state inspections, most recent first.
A CNA transported two residents in wheelchairs at the same time, leading to one resident's wheelchair catching on a window frame and causing a fall with a hip fracture. The resident, who had rheumatoid arthritis and contractures, was not using foot pedals as per her care plan. Staff interviews revealed inconsistent understanding of safe transport protocols and a lack of recent education on fall prevention. The facility's investigation was limited and did not include comprehensive staff education or clear documentation of safety expectations.
Staff did not consistently document food temperatures for 40 out of 192 meals, resulting in a lack of evidence that meals were heated to safe temperatures before serving. The dietary manager and interim administrator confirmed that kitchen staff were responsible for this documentation, and that missing records meant there was no proof food safety standards were met.
A resident with severe cognitive impairment, vascular dementia, and a known history of wandering eloped from the facility despite having a wander guard device and care plan interventions in place. After the front door wander guard alarm sounded, a CNA checked the immediate area but did not locate the resident, who was later found by an RN walking off the premises. The incident demonstrated a failure to provide adequate supervision and ensure the safety of a resident at high risk for elopement.
Surveyors found expired medications, including Tylenol, Carbidopa/Levodopa, Diphenhydramine, and Gabapentin, on two medication carts. Both an RN and a CMA confirmed the expired drugs were present and should have been removed by night nursing staff. The DON stated there was no checklist or policy for checking and removing expired medications, leading to the deficiency.
The facility failed to adequately supervise residents who smoked or vaped, resulting in a burn injury and inconsistent safety assessments. Additionally, a resident with a history of elopement was allowed to walk unsupervised and left the facility grounds without staff knowledge, highlighting deficiencies in the implementation of safety policies.
A resident with paraplegia suffered a burn on her abdomen from a hot microwave meal prepared by an RN. The RN followed package instructions and informed the resident about the meal's temperature, but later found blisters on the resident's abdomen. The RN documented the injury and applied a dressing but did not complete a risk management report or notify the primary care provider immediately.
Two residents' care plans were found to be incomplete and not individualized, failing to reflect their current needs for ADL and pressure ulcer prevention. Despite using pressure-relieving equipment, their care plans lacked specific interventions. Staff interviews revealed issues with updating care plans due to unfamiliarity with the EMR system and recent staff vacancies.
Failure to Prevent Accident During Wheelchair Transport Results in Resident Injury
Penalty
Summary
A certified nursing assistant (CNA) failed to safely transport a resident in a wheelchair, resulting in the resident falling and sustaining a fractured hip. The CNA was pushing two residents simultaneously in their wheelchairs when one wheelchair caught on a window frame, causing the resident to fall forward onto her right hip. The resident, who had rheumatoid arthritis and contractures in her hands and knees, experienced significant pain and required emergency surgery for the hip fracture. The incident was witnessed by staff and captured on security video, confirming that the CNA was pushing two residents at once, which was not the proper procedure. Interviews with staff and residents revealed that there was inconsistency in staff understanding and adherence to safe wheelchair transport protocols. Several staff members, including CNAs and LPNs, reported that they had not received recent education or follow-up training regarding safe resident transportation or fall prevention policies. Some staff were unaware of the facility's policies or where to find them, and there was confusion among newer staff about whether transporting two residents at once was acceptable. The facility's investigation documentation did not include evidence of comprehensive staff education or clear communication of safety expectations following the incident. The resident involved in the fall had a care plan indicating dependence on staff for wheelchair locomotion and a need for reminders to use foot pedals, which she often refused due to her contractures. At the time of the incident, the resident was not using foot pedals, and the facility had noted a general lack of available wheelchair foot pedals. The facility's falls policy did not include provisions for staff education to prevent falls, and the investigation into the incident was limited, with only the CNA and the resident directly involved being interviewed. No disciplinary action or formal follow-up education was documented for the staff involved.
Failure to Document Food Temperatures for Resident Meals
Penalty
Summary
The facility failed to follow food safety standards by not consistently monitoring and documenting food temperatures for meals served to residents. Specifically, for 40 out of 192 meals served between 5/1/25 and 8/3/25, there was no documentation to confirm that food temperatures were checked prior to serving. Observations in the kitchen revealed that while temperature log books for breakfast, dinner, and supper were present, staff acknowledged that some meal temperatures were not recorded. The cook confirmed that not all food temperatures were documented, and the certified dietary manager also acknowledged the lack of documentation for certain meals. Interviews with the certified dietary manager and the interim administrator confirmed that the responsibility for checking and documenting food temperatures rested with the kitchen staff, and that missing documentation meant there was no proof that food was heated to the required safe temperatures before being served. Review of the facility's food preparation and service policy outlined specific temperature requirements for various foods, but the lack of consistent documentation indicated that these standards were not always met.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure the safety and adequate supervision of a resident identified as being at high risk for elopement. The resident, who had severe cognitive impairment, vascular dementia, a history of wandering, and was ambulatory, was last seen on the unit by staff before the front door wander guard alarm was triggered. After the alarm sounded, a CNA responded, checked the immediate area outside the front door and parking lot, but did not see anyone and returned to the facility, shutting off the alarm. Staff were then notified and a facility-wide search was initiated. The resident was eventually found by an RN walking approximately two-tenths of a mile from the facility, having left without staff knowledge. The resident's medical record indicated a history of wandering and a high risk for elopement, with care plan interventions in place, including the use of a wander guard device and regular checks to ensure its functionality. Despite these interventions, the resident was able to exit the facility undetected and was not immediately located after the alarm was triggered. The incident was reported to the DON, administrator, and tribal police, and the resident was returned safely to the facility. The failure to provide adequate supervision and respond effectively to the elopement risk resulted in the resident leaving the facility unsupervised.
Expired Medications Found on Medication Carts Due to Lack of Policy and Oversight
Penalty
Summary
Surveyors observed that two medication carts contained expired medications, including Tylenol 325 mg, Carbidopa/Levodopa 25/100 mg, Diphenhydramine 25 mg, and Gabapentin 600 mg. These expired medications were available for administration to residents. Both a registered nurse and a certified medication aide confirmed the presence of expired medications and acknowledged that night nursing staff were responsible for checking and removing expired medications from the carts. Further interviews with the director of nursing revealed that there was no night shift checklist that included the task of checking for expired medications, and the facility did not have a policy regarding expired medications. The lack of a formal process or policy contributed to the failure to remove expired medications from the medication carts.
Deficiencies in Resident Supervision and Safety
Penalty
Summary
The report identifies several deficiencies related to the supervision and safety of residents who smoke or vape at the facility. Specifically, the facility failed to effectively implement and follow its smoking policy for multiple residents. One resident suffered a cigarette burn on her abdomen due to inadequate supervision and refusal to wear a smoking apron, which was a required safety measure. The facility's smoking policy required residents to be supervised while smoking, but observations revealed that supervision was sometimes conducted from inside the building, which may not have been adequate. Additionally, the facility did not have a vaping policy, and the smoking safety screens were not consistently completed or updated for residents who smoked or vaped. Another significant deficiency involved a resident with a known history of elopement who was allowed to walk outside the facility unsupervised. This resident, who had moderate cognitive impairment, left the facility grounds without staff knowledge and was missing for over an hour. The facility's policy required residents at risk of elopement to be adequately supervised, but the resident was permitted to walk alone as a non-pharmacological intervention for his behaviors. The facility's response to the resident's absence was delayed, and the resident was eventually found at a nearby apartment complex. The facility's policies on smoking and elopement were not adequately followed or enforced, leading to safety risks for the residents involved. The lack of consistent smoking safety assessments and the failure to update care plans to reflect residents' current needs contributed to these deficiencies. The facility's elopement policy required systematic monitoring and management of residents at risk, but the implementation of these measures was insufficient, as evidenced by the resident's unsupervised departure from the facility.
Resident Suffers Burn from Hot Microwave Meal
Penalty
Summary
A resident with a diagnosis of paraplegia suffered a skin burn wound on her abdomen from hot food prepared by a registered nurse (RN) in a microwave. The incident occurred when the resident requested the RN to make a freezer meal in the microwave. The RN cooked the meal according to package instructions and informed the resident that the item was hot and advised her to let it cool before eating. Later, when the RN assisted the resident into bed, she noticed a red circle mark with four blisters on the resident's abdomen. The RN documented the skin condition in the resident's chart and applied a Mepilex dressing to the blistered area. However, the RN did not complete a risk management report or immediately notify the primary care provider to obtain orders for the burn. The incident was reported to the morning nurse, but the facility initially did not consider it a reportable incident due to the education provided to the resident about the hot meal.
Incomplete and Non-Individualized Care Plans for Residents
Penalty
Summary
The provider failed to ensure that care plans reflected the current individualized activities of daily living (ADL) and pressure ulcer prevention and treatment needs for two residents. Resident 2, who has paraplegia and a pressure ulcer, was observed using an air mattress and positioning cushions for pressure relief. Despite these observations and her reliance on staff for most care needs, her comprehensive care plan did not include interventions for her pressure ulcer or prevention measures. Similarly, Resident 1, diagnosed with alcohol-induced persisting dementia and muscle weakness, was observed using an air mattress and a pressure-relieving cushion. However, his care plan lacked complete and individualized focus areas, goals, and interventions, including those for pressure ulcer prevention. Interviews with staff revealed systemic issues in care plan management. A certified nursing assistant (CNA) and a registered nurse (RN) described using care sheets and electronic medical records (EMR) for documenting resident care, but these were not consistently updated to reflect current needs. The Minimum Data Set (MDS) coordinator acknowledged that the care plans for both residents were incomplete and not individualized, attributing this to her unfamiliarity with the new Point Click Care (PCC) EMR system. The administrator confirmed that care plans were not updated as expected due to recent staff vacancies, which affected the weekly review process. The facility's policy on Pressure Injury Risk Assessment emphasized the need for resident-centered care plans based on risk factors, skin condition, and clinical status. However, the care plans for the two residents did not align with these standards, as they were not modified to reflect changes in the residents' conditions or deemed inadequate interventions. This lack of adherence to policy contributed to the deficiencies observed in the care plans.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Flandreau
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverview Healthcare Center | 1 mi | ★★★★★ | 11 | 1 |
| Good Samaritan Society - Pipestone | 14.2 mi | ★★★★★ | 1 | 1 |
| Dells Nursing And Rehab Center Inc | 15.3 mi | ★★★★★ | 4 | 0 |
| The Neighborhoods At Brookview | 20 mi | ★★★★★ | 2 | 0 |
| United Living Community | 21.1 mi | ★★★★★ | 9 | 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.