Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Michael J Fitzmaurice South Dakota Veterans Home during CMS and state inspections, most recent first.
A resident with significant cognitive and physical impairments developed new pressure ulcers on his toes due to inconsistent implementation of physician-ordered wound care and preventative interventions. Staff failed to consistently apply protective boots, silicone toe spacers, and avoid socks as ordered, and there were missed or undocumented wound care treatments. Facility policy requiring regular skin assessments and use of pressure-reducing devices was not consistently followed, resulting in additional pressure ulcers.
A resident with multiple complex medical conditions experienced vomiting during supper, but an LPN failed to assess the resident, document the event, initiate standing orders, or adjust the resident's diet. The resident was returned to the dining room, consumed a full meal, and later aspirated on emesis and died. Staff interviews and records confirmed the LPN did not perform required assessments or interventions after the incident.
Surveyors found that staff failed to follow infection control protocols, including hand hygiene and PPE use, for residents on contact and enhanced barrier precautions. PPE supplies were not consistently available, and staff were observed providing care and cleaning without required gowns or gloves. Wound care supplies for multiple residents were stored together in non-cleanable bins, with expired and unlabeled items present. There was confusion among staff about infection control requirements and inconsistent documentation of physician orders for precautions.
Two residents who smoked were allowed to keep their lighters and cigarettes in their possession, contrary to facility policy requiring these items to be stored at the nurses' station. One resident had moderate cognitive impairment and sometimes forgot to turn in her lighter, while the other, who was cognitively intact, kept his smoking materials because staff did not request their return. Staff interviews confirmed inconsistent enforcement of the policy, and documentation showed both residents had signed agreements and care plans specifying that smoking materials should be secured by staff.
Five residents with bed rails did not have documented assessments to determine safe use or measurements for entrapment risk, despite policy requiring monthly inspections and safety checks. Staff interviews confirmed that regular maintenance and safety assessments had not been performed since early 2023, and key personnel were unaware of the ongoing requirements.
A resident with severe cognitive impairment and multiple medical conditions did not have an updated care plan reflecting current care needs, including changes in mobility, use of compression stockings, and pressure injury management. Staff used inconsistent care plans, and the EMR care plan was not revised to match physician orders or the resident's actual condition, leading to discrepancies in care.
Failure to Consistently Implement Pressure Ulcer Prevention and Treatment Orders
Penalty
Summary
A resident with multiple complex medical conditions, including Parkinson's disease, dementia, chronic pain, and a history of partial toe amputation, was identified as being at moderate risk for skin breakdown based on a Braden scale score of 13-14. The resident had existing pressure ulcers on his toes and was under physician orders for specific wound care treatments and preventative interventions, such as the use of foam boots, silicone toe spacers, and a bed cradle to relieve pressure and prevent further skin breakdown. Despite these orders, observations revealed that the resident was not consistently provided with the prescribed interventions. For example, the resident was repeatedly observed in a recliner without protective boots, and gripper socks were seen on his feet despite orders against their use. Additionally, the silicone spacers intended to separate his toes were not always in place, and there were instances where alternative materials were used due to missing spacers. Review of the treatment administration record (TAR) showed multiple missed or undocumented wound care treatments and preventative measures, including the application of foam boots and wound dressings. Staff interviews indicated confusion regarding the timing and application of protective boots, with some staff believing they were only required in bed, while orders specified use in the morning, evening, and nighttime. There was also a lack of clarity among staff about the use of socks and the need for continuous toe separation. Documentation further revealed that the resident developed new pressure ulcers on additional toes during his stay, with the likely cause identified as continuous pressure between the toes, exacerbated by inconsistent use of spacers and protective devices. The facility's own pressure ulcer prevention and treatment policy required regular skin assessments, implementation of prevention protocols based on Braden scores, and the use of pressure-reducing devices as ordered for all settings, including recliners. However, these protocols were not consistently followed for this resident. The failure to implement and document ordered treatments and preventative interventions led to the development of new pressure ulcers and the lack of consistent care for existing wounds.
Failure to Assess and Intervene After Resident Emesis Leading to Neglect
Penalty
Summary
A licensed practical nurse (LPN) failed to initiate standing orders for a resident who experienced an episode of emesis (vomiting) in the dining room prior to the evening meal. After the incident, staff took the resident to his room to clean him up and then returned him to the dining room, where he was served and consumed a full regular meal. There was no documentation by the LPN of the emesis, no assessment of the resident's condition, no vital signs taken, and no changes made to the resident's diet, such as switching to clear liquids, despite reports from other staff that the resident was not feeling well and had stomach pains. The resident, who had multiple diagnoses including dementia, COPD, atrial fibrillation, diabetes, chronic kidney disease, PTSD, Parkinson's disease, and hypertension, and was severely cognitively impaired, later aspirated on his emesis and passed away in his room that night. Staff interviews confirmed that the LPN did not perform necessary assessments or initiate appropriate interventions following the emesis. The LPN also failed to communicate a comprehensive change of condition during shift reporting, only mentioning the emesis once and stating the resident was fine. Further review revealed ongoing concerns with the LPN's performance, including lack of safety measures, improper documentation, failure to assess residents' conditions, and medication administration errors. The LPN had previously undergone multiple coaching sessions and was under close supervision due to these issues. The deficiency was identified through facility-reported incident review, observation, record review, and staff interviews.
Failure to Implement and Maintain Infection Control Practices and Proper PPE Use
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices within the facility, particularly regarding hand hygiene, personal protective equipment (PPE) use, and the storage and maintenance of wound care supplies. Staff members, including LPNs and homemakers, were observed entering and exiting the rooms of residents on contact precautions or enhanced barrier precautions (EBP) without performing hand hygiene or donning required PPE such as gowns and gloves. PPE supplies were not consistently available outside or inside the rooms of residents requiring precautions, and signage for contact precautions was missing for a resident with an active wound infection and a history of MRSA. Staff were also observed performing direct care and environmental tasks without appropriate PPE, and some were unaware of the specific requirements for residents on EBP or contact precautions. A resident with chronic kidney disease, a recent dialysis fistula, a central line, and a history of chronic empyema with an unhealed, infected chest wound was not placed on contact precautions as ordered by the physician. The resident had a history of MRSA and was receiving antibiotics for a surgical wound infection, yet staff did not consistently follow the required infection control measures. Observations revealed that wound care supplies were not stored in resident rooms but were instead kept in shared treatment carts or storage rooms, with supplies for different residents sometimes stored together in non-cleanable cardboard bins. Multi-use items such as scissors were visibly soiled, and expired or unlabeled wound care supplies were found in the treatment cart. Interviews with staff, including the DON and infection preventionist, revealed confusion and inconsistency regarding the storage and availability of PPE, as well as the implementation of EBP and contact precautions. Staff were unclear about the specific precautions required for residents with chronic wounds or MDROs, and there was a lack of clear communication and documentation regarding physician orders for infection control measures. The facility's policies required proper storage, labeling, and dating of supplies, as well as adherence to PPE protocols, but these were not consistently followed, leading to the identified deficiencies.
Failure to Secure Smoking Materials According to Facility Policy
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not following its own policy regarding the storage of smoking materials for two residents who smoked. Observations revealed that both residents were able to retain possession of their lighters and cigarettes, rather than having them secured at the nurses' station as required by facility policy. One resident, who had moderate cognitive impairment due to vascular dementia and depression, was observed with her own lighter and admitted to sometimes forgetting to turn it in to staff. The other resident, who was cognitively intact but had PTSD and depression, also kept his smoking materials with him and stated that staff did not request their return, despite being aware of the policy. Staff interviews confirmed inconsistent enforcement of the smoking materials policy. Multiple staff members, including homemakers, the household coordinator, and the DON, acknowledged that residents' smoking materials were not always checked in and out as required. Staff cited difficulties in tracking lighters, especially when residents purchased new ones during outings, and admitted that some residents routinely kept their smoking materials in their possession. The social worker and household coordinator both expected staff to ensure compliance with the policy, but were unaware that the two residents had their lighters with them. Review of facility documentation, including smoking assessments, care plans, and the smoking policy, showed that both residents had signed smoking agreements and had been instructed on the policy, which clearly stated that all smoking materials were to be stored at the nurses' station and not kept in residents' rooms. The care plans for both residents specifically required staff to secure their smoking materials. Despite these documented requirements, the facility did not consistently implement its policy, resulting in residents retaining access to lighters and cigarettes.
Failure to Assess and Document Bed Rail Safety
Penalty
Summary
The facility failed to assess bed rails for safe use for five sampled residents who had bed rails on their beds. Observations revealed that each of these residents had bed rails or grab bars on both sides of their beds, but there was no documentation that an assessment had been completed to determine the safe use of the bed rails or to measure the risk of entrapment and injury. The residents' electronic medical records indicated that device evaluations for bed rail use had been completed at various times, but none included the required safety assessments or measurements. Interviews with staff revealed further gaps in the facility's practices. The physical therapist reported that she had assessed bed rails for all residents using them in early 2023 but had not conducted any regular maintenance inspections since then. The physical plant manager stated he had not completed measurement assessments for the safe use of bed rails for any residents and was unaware that such assessments had not been performed since 2023. The DON was also unaware of the need for regular maintenance inspections or measurements to determine the safe use of bed rails. A review of the facility's undated Bed Safety policy indicated that monthly inspections of all bed frames, mattresses, and bed rails were required as part of a regular preventative maintenance program. The policy also required that gaps within the bed system be reviewed to ensure they were within FDA-established dimensions and that bedrails be properly installed according to manufacturer instructions. Despite these policy requirements, the facility did not have documentation or evidence that these inspections and assessments were being performed as required.
Failure to Update and Revise Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised to reflect current care needs. Observations showed the resident, who was severely cognitively impaired and had multiple diagnoses including Parkinson's, dementia, chronic pain, and pressure injuries, was inconsistently using protective boots and compression stockings. The care plan in the electronic medical record (EMR) indicated the resident should wear compression stockings and foam boots in bed, but did not specify use of boots in the recliner, nor did it reflect that the resident was no longer able to walk or that compression stockings were discontinued per family request. Staff interviews revealed confusion and inconsistency regarding which care plan to follow, with some staff using a baseline care plan and others referencing the EMR, leading to discrepancies in care provided. Further review of the resident's records and staff interviews confirmed that the care plan was not updated to include new orders or changes in the resident's condition, such as the development of pressure wounds and changes in mobility status. The facility's own policies required that care plans be updated to reflect current wound status and treatment, and that changes in condition be reported and documented accordingly. However, the care plan did not accurately reflect the resident's current needs or physician's orders, resulting in a failure to provide consistent and appropriate care as required.
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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 Hot Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seven Sisters Living Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Custer Care And Rehab Center | 23.6 mi | — | 38 | 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.