Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Monument Health Sturgis Care Center during CMS and state inspections, most recent first.
Staff failed to follow infection control practices during blood sugar testing, medication prep, and wound care. An RN used the same gloves while handling the computer, glucometer supplies, and a resident’s finger stick, and later acknowledged she should have removed the gloves and performed hand hygiene first. A CMA touched medications with taped fingers that were uncleanable, and an RN performing wound care did not wear a gown despite enhanced barrier precautions requiring gloves and a gown for wound care.
A RN handed a resident a Trelegy Ellipta inhaler so the resident could self-administer it, even though there was no provider order for self-administration of that specific medication and no self-administration assessment for the inhaler. The DON's assessment covered the resident's nebulizer use only, and both the RN and DON confirmed the resident was not assessed or ordered to self-administer the inhaler, despite the facility policy requiring competency determination and a provider order for each medication.
A CMA administered the wrong dose of potassium chloride ER to a resident after verifying the MAR and blister pack label matched. The CMA gave one tablet even though the physician’s order required 2 tablets by mouth daily, and the DON confirmed the dose was incorrect. Facility competency guidance stated staff were expected to follow the rights of medication administration, including the right dose.
Illegible and Expired Insulin Pens Used for Two Residents: Staff found a Lispro insulin pen with a smeared label and an expired open date for one resident, yet insulin from that pen was documented as given five times after expiration. A second resident’s Lantus insulin pen also had an illegible pharmacy label, and an RN confirmed staff could not properly compare the label to the MAR before administration. The DON stated staff were expected to review medication packaging and labels for expired medication, and the facility policy required illegible medication labels to be returned to the pharmacy or destroyed.
A resident with severe cognitive impairment and multiple medical conditions developed several bruises of unknown origin over a period of weeks. Nursing staff failed to measure, describe, or identify the causes of these bruises, and did not complete required Incidence/Variance reports to investigate or rule out abuse or neglect, as required by facility policy. The care plan did not address the resident's risk for bruising, and documentation was incomplete.
A resident fell after attempting to reach a call light that was not positioned within reach following a transfer to a recliner. The responsible CNA did not ensure the call light was accessible, which was contrary to facility policy and training. This failure to follow fall prevention protocols led directly to the resident's fall.
A resident in a long-term care facility experienced inadequate pain management due to the facility's failure to ensure timely acquisition and administration of prescribed pain medication. Observations revealed discrepancies in controlled substance counts and improper handling of medications, leading to unavailability of necessary pain relief for the resident.
The facility failed to remove expired medications from medication and treatment carts, with several medications found past their expiration dates. Observations revealed that medications were not consistently dated when opened, and staff interviews indicated that checking expiration dates was not assigned to a specific nurse or shift. The director of nursing expected medications to be dated upon opening, but this practice was not consistently followed, leading to the deficiency.
A suspected case of medication diversion involving oxycodone was not reported within the required time frame. An RN discovered missing medication, and the DON confirmed the loss but delayed reporting to the SD DOH and law enforcement, violating the facility's policy and state regulations.
The facility failed to maintain appropriate temperatures for a high-temperature dishwasher used for resident food service. Observations showed that many recorded temperatures were below the manufacturer's recommended levels, with no corrective actions documented. Interviews revealed inconsistent responses from staff regarding maintenance calls and corrective measures.
A temporary RN failed to administer the correct insulin dosage to a resident, not following the facility's policy of priming the insulin pen. The RN prepared 8 units instead of the ordered 10 units and was unaware of the priming requirement. The DON had not audited the RN's skills, assuming proficiency from the agency's training.
The facility failed to provide adequate oral hygiene for three residents dependent on staff for care. One resident, moderately cognitively impaired, received oral care only 10 out of 52 opportunities. Another resident, under hospice care with severe cognitive impairment, received care 10 out of 60 times. A third resident, also severely cognitively impaired, showed signs of poor oral hygiene and received care 13 out of 60 times. The DON was unaware of these deficiencies, which violated the facility's policy requiring twice-daily oral care.
A resident with severe cognitive impairment and a history of UTIs was not consistently encouraged to meet her daily fluid intake needs, and staff failed to provide proper peri-care, increasing her risk of UTIs. The resident was not on a scheduled toileting program, and her fluid intake was often below the estimated requirement. Observations revealed inadequate peri-care practices, such as reusing soiled wipes and improper hand hygiene, contributing to the deficiency.
The facility failed to implement proper infection control practices during peri-care and incontinence care. Observations showed CNAs reusing soiled wipes, not changing gloves between dirty and clean tasks, and neglecting resident hand hygiene post-toileting. Despite training, staff did not consistently follow protocols, as confirmed by interviews and policy reviews.
The facility was found deficient in ensuring all nursing staff were properly educated and competent in using mechanical lifts, leading to improper transfers and potential safety risks for residents.
Infection Control Failures During Blood Sugar Checks, Medication Prep, and Wound Care
Penalty
Summary
The provider failed to ensure staff followed infection prevention and control practices during blood sugar testing, medication administration, and wound care. During an observation of RN E checking resident 29’s blood sugar, RN E used gloved hands to touch the computer keyboard and mouse, retrieved supplies from the medication cart, and entered the resident’s room without removing the gloves or performing hand hygiene first. She then used the same gloves to insert the test strip, wipe the resident’s finger, perform the finger stick, and apply blood to the glucometer strip before leaving the room, removing the gloves, performing hand hygiene, and disinfecting the glucometer. RN E later stated she should have removed the gloves, performed hand hygiene, and put on clean gloves before checking the blood sugar, and the DON stated the same expectation. During medication preparation for resident 24, CMA F performed hand hygiene but had clear medical tape around two fingers and used those bare taped fingers to touch individual pills while pushing them out of ten blister packs into a medication cup. She periodically used alcohol-based hand sanitizer while preparing the medications. After administration, she stated there was no medical reason for the tape, removed it, and acknowledged it was discolored and unclean and that she had touched some of the medications with those taped fingers. The DON stated the medications were expected to be pushed directly from the blister packs into the cup and that the tape was an uncleanable surface that should not have been worn for non-medical reasons. During wound care for resident 13, RN E performed hand hygiene, donned gloves, removed the resident’s unclean wound dressing, discarded it, removed her gloves, performed hand hygiene, and put on a new pair of gloves before cleaning the open wound. After cleaning the wound, she applied hydrogel and a foam dressing, then discarded supplies, removed her gloves, and performed hand hygiene. RN E acknowledged that the gloves used after touching the open wound were dirty and that she did not wear a gown during the wound care, despite an enhanced barrier precautions sign outside the room directing staff to wear a gown and gloves for wound care. The DON/infection preventionist stated staff were expected to perform hand hygiene after cleaning a wound and before donning new gloves, and to follow the enhanced barrier precautions sign requiring a gown for high-contact care such as wound care.
Unapproved Self-Administration of Inhaler
Penalty
Summary
A RN provided a Trelegy Ellipta inhaler to a resident for self-administration even though there was no physician's order authorizing self-administration of that specific inhaler and no medication self-administration assessment for the inhaler. During observation, the RN compared the inhaler box label to the MAR, cleaned her hands, brought the inhaler to the resident's room, and handed it to the resident, who then self-administered one puff and returned the inhaler to the RN. The resident then swished water in her mouth and spit it into a basin before handing the inhaler back. Record review showed the resident had a self-administration assessment completed by the DON that addressed the resident's ability to self-administer her nebulizer treatment, but it did not include the inhaler. The RN stated a physician's order was needed before a resident could self-administer a medication and confirmed the resident did not have an order allowing self-administration of the inhaler. The DON stated she did not evaluate the resident's ability to self-administer the inhaler because she did not know the resident wanted to self-administer that medication, and confirmed the resident was not assessed and did not have a physician's order for self-administration of the inhaler. The facility's revised Medication: Self Administration policy stated that self-administration requires the resident to be deemed competent by the provider and requires a provider's order for that specific medication.
Incorrect Dose of Potassium Chloride ER Administered
Penalty
Summary
A certified medication aide (CMA) failed to administer potassium chloride ER to a resident according to the physician’s order. During observation, the CMA compared the blister pack label to the resident’s MAR and confirmed they matched, then pushed one potassium chloride ER tablet into a medication cup and administered the resident’s medications. After the resident swallowed the medications, the CMA returned to the cart and documented the medication administration as completed. During interview, the CMA confirmed she gave only one potassium chloride ER tablet to the resident and then re-read the physician’s order, which directed that 2 tablets be given by mouth one time a day. The DON later confirmed that the CMA failed to administer the correct dose. Review of the facility’s Medication Administration Clinical Skills Checklist showed staff were expected to complete the rights of medication administration, including the right drug, dose, route, time, and patient.
Illegible and Expired Insulin Pens Stored and Used
Penalty
Summary
The facility failed to ensure resident insulin pens were labeled in a way staff could read and that expired insulin was removed from use. During observation and interview, a Lispro insulin pen stored in the medication cart for resident 30 had a smeared pharmacy label, with only the resident’s first name legible. The RN stated she did not routinely compare the insulin pen label to the MAR for discrepancies before administration and would only use the pen label to confirm it belonged to the resident. The pen box showed an open date and an expiration date, and the RN confirmed the insulin pen was expired. The pen was supposed to be removed and discarded, but the MAR showed resident 30 received insulin from that expired pen five times between the documented dates. A second observation found a Lantus insulin pen in the medication cart for resident 39 with an illegible pharmacy label except for the resident’s first name. The RN stated staff were expected to compare the pharmacy label to the MAR and reconcile discrepancies before administering insulin, but confirmed that expectation could not be followed because the label was illegible. The DON stated staff were expected to review medication packaging and labels for expired medication before administration, and the facility’s Medication Labels policy stated that medication containers with soiled, damaged, incomplete, illegible, or makeshift labels are to be returned to the pharmacy for relabeling or destroyed according to facility medication policy.
Failure to Investigate and Document Bruises of Unknown Origin
Penalty
Summary
The provider failed to thoroughly investigate bruises of unknown origin for a cognitively impaired resident who required assistance with all activities of daily living. Over several weekly skin assessments, multiple bruises and areas of discoloration were documented on the resident's arms, knees, thighs, and forearms. These assessments lacked measurements, clear descriptions, and did not identify the cause or potential cause of the bruises. Additionally, there was no documentation of interventions to prevent further bruising, and the care plan did not reflect a history or risk of frequent bruising for the resident. Nursing staff did not complete required Incidence/Variance reports for the bruises of unknown origin, which would have triggered an investigation to determine the root cause, rule out abuse or neglect, and develop preventive interventions. The facility's policy required such reports for unexplained bruises, but this process was not followed. Interviews with supervisory staff confirmed that the expected procedures for assessment and reporting were not adhered to, and that the documentation in the electronic medical record was incomplete regarding the nature and management of the resident's skin injuries.
Failure to Ensure Call Light Accessibility Resulted in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement a fall prevention intervention by not ensuring a resident's call light was within reach after the resident was positioned in his recliner. The resident, who was able to call out for help and use his call light, was found on the floor after attempting to reach for his call light, which was not accessible to him at the time. The incident was identified after staff heard the resident calling for help and found that he had fallen while trying to access his call light from his recliner. Review of the incident revealed that the certified nurse aide responsible for the resident did not position the call light within the resident's reach after transferring him to the recliner, contrary to facility policy and training. Observations of other residents confirmed that staff generally ensured call lights were accessible, but in this specific case, the failure to do so directly led to the resident's fall. The root cause was identified as the staff member's failure to follow established fall prevention protocols.
Medication Management Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that prescribed pain medication was acquired and administered in a timely manner for a resident experiencing pain. On January 31, 2025, two tablets of oxycodone were found in an unoccupied room, and by February 3, 2025, it was reported that the resident's as-needed medication card of oxycodone could not be located. The Director of Nursing confirmed that the medication card and the controlled medication count sheet were unaccounted for. An audit revealed additional missing controlled medication sheets over the past year. Observations on February 19, 2025, revealed discrepancies in the controlled substance count process. The shift audit records were not consistently signed by both the outgoing and incoming nurses, indicating that controlled medication counts were not properly conducted. Additionally, an unlicensed medication aide mistakenly punched out an oxycodone tablet and attempted to secure it back into the card with tape, without notifying anyone of the error. This incident highlights a lack of adherence to proper medication handling and documentation procedures. The resident involved had a history of chronic pain, rheumatoid arthritis, and other conditions requiring pain management. Despite having a care plan in place to manage pain, the resident experienced severe pain on February 1, 2025, and was given Tylenol instead of the prescribed oxycodone due to its unavailability. The Director of Nursing was unaware of the delay in receiving the replacement medication card until February 10, 2025, and acknowledged that there were alternative methods to obtain the medication in an emergency. The facility's failure to maintain accurate records and ensure timely medication administration resulted in inadequate pain management for the resident.
Expired Medications Found in Facility Carts
Penalty
Summary
The facility failed to ensure expired medications were removed from medication and treatment carts, as observed on multiple occasions. On the [NAME] hallway treatment cart, several medications were found to be past their expiration dates, including Hydrocodone/acetaminophen, Novolog insulin pen without an opening date, CalProtect ointment, Nystatin powder, Ketoconazole ointment, Diclofenac gel, Tacrolimus ointment, Ciclopirox topical solution, and Nitroglycerin tablets. Additionally, the Berry hallway medication cart contained Latanoprost eye drops without an opening date. Interviews with staff revealed that checking expiration dates was not assigned to a specific nurse or shift, and medications were not consistently dated when opened. The director of nursing expected nurses and unlicensed medication aides to date medications upon opening, but this practice was not consistently followed. The facility's policy on the expiration of medications stated that all 'time-dated' medications should have an expiration date printed on the container, and the earlier of the manufacturer's date or the date based on opening should be followed. The Abridged List of Medications with Shortened Expiration Dates indicated specific shortened expiration periods for medications like Latanoprost and Novolog, which were not adhered to, leading to the deficiency.
Delayed Reporting of Medication Diversion Incident
Penalty
Summary
The provider failed to report a suspected case of controlled medication diversion within the required time frame. On January 31, 2025, two tablets of oxycodone were discovered by an RN in an unoccupied room. By February 3, 2025, the RN informed the DON that a resident's medication card for oxycodone was missing. The DON confirmed the missing card and initiated an internal investigation. However, the report to the South Dakota Department of Health (SD DOH) and law enforcement was not filed until February 5, 2025, which was beyond the required 48-hour notification period after becoming aware of the incident. The facility's policy mandates that any suspected abuse, including theft or misappropriation of resident property, must be reported to the Department of Health within 48 hours. Despite the internal investigation and confirmation of missing medication logs, the DON delayed reporting the incident due to uncertainty about the missing medication. This delay in reporting violated the facility's policy and state regulations, as the initial report should have been filed within 24 hours of the occurrence of such an incident.
Failure to Maintain Dishwasher Temperatures
Penalty
Summary
The facility failed to maintain appropriate temperatures for a high-temperature dishwasher used to clean dishes for resident food service. Observations and interviews revealed that the wash cycle temperature was supposed to be between 170 and 175 degrees Fahrenheit, and the final rinse cycle between 180 and 190 degrees Fahrenheit. However, the Dishmachine Temperature Record for September 2024 showed that 19 out of 90 wash temperatures and 36 out of 90 rinse temperatures were below the manufacturer's recommended minimal temperature. No corrective actions were documented when temperatures fell below the required levels. Interviews with various staff members, including the kitchen director, kitchen manager, dishwasher, and plant operations manager, indicated a lack of consistent action when temperatures were inadequate. While some staff members reported calling maintenance to service the dishwasher, others did not, and there was a general lack of documentation regarding corrective actions taken. The director of nursing confirmed that some temperatures were below the recommended levels, but there were no reports of gastrointestinal illness during September.
Insulin Administration Deficiency by Temporary RN
Penalty
Summary
The provider failed to ensure that a registered nurse (RN) prepared and administered insulin according to the physician's order and facility policy for a resident. During an observation, the RN prepared 8 units of insulin instead of the ordered 10 units for a resident who was to receive Novolog insulin every morning after breakfast. The RN did not prime the insulin needle before dialing up the dosage, which is against the facility's policy. Upon being stopped by a surveyor, the RN verified the correct dosage and adjusted the insulin pen to the correct amount before the resident self-administered the insulin. The RN, who was working as a temporary nurse, admitted to not being aware of the need to prime the insulin pen and had not undergone an insulin administration skills audit at the facility. The Director of Nursing (DON) assumed that travel nurses received insulin skills education from their agency and had not audited the nursing staff for insulin injection skills. The facility's policy clearly stated the need to prime the needle with 2 units of insulin before administration, which was not followed in this instance.
Failure to Provide Adequate Oral Hygiene for Dependent Residents
Penalty
Summary
The provider failed to ensure oral hygiene was provided for three residents who were dependent on staff for their care needs, as per their personalized care plans and facility policy. Resident 3, who was moderately cognitively impaired, required partial to moderate assistance for oral care twice a day. However, documentation revealed that oral care was provided only 10 out of 52 opportunities, excluding the days she was hospitalized. Resident 45, receiving hospice care with severe cognitive impairment, also required similar assistance but received oral care only 10 out of 60 opportunities, with one refusal documented. His wife, who was his power of attorney, expressed concerns about the lack of oral care provided by the staff. Resident 148, with severe cognitive impairment, required substantial to maximal assistance for oral care. Observations revealed poor oral hygiene, including phlegm build-up and a white pasty coating on his teeth. Documentation showed that oral care was provided only 13 out of 60 opportunities. The Director of Nursing was unaware that oral care was not being provided according to care plans or policy. The facility's policy required dental care to be provided in the morning and at bedtime, with documentation of the procedure in the electronic health record.
Failure to Implement UTI Prevention Interventions
Penalty
Summary
The provider failed to implement interventions to reduce the occurrence of urinary tract infections (UTIs) for a resident with a history of UTIs. The resident, who had severe cognitive impairment and was incontinent of urine 93% of the time, was not consistently encouraged to meet her daily fluid intake needs. Observations revealed that staff did not provide verbal cues or encouragement to drink fluids during meals, and her fluid intake was often below the estimated daily requirement. Additionally, the resident was not on a scheduled toileting program, which could have minimized the time she remained incontinent. Interviews with staff indicated a lack of awareness regarding the resident's fluid intake needs and the absence of a scheduled toileting program. The resident was sometimes left with a full cup of water overnight, and staff did not offer her water from the bedside cup before leaving her room. Furthermore, the resident was bathed only once a week, and there was no documentation of attempts to increase her fluid intake or adjust her bathing schedule to prevent UTIs. The peri-care provided to the resident was inadequate, as observed during an incident where CNAs reused soiled wipes and failed to perform proper hand hygiene. This improper peri-care increased the resident's risk of developing UTIs. The facility's UTI occurrence rates were above both state and national averages, and the director of nursing acknowledged that the resident's fluid intake expectations were not consistently met. The facility's action plan to address the high UTI rates focused on monitoring residents and educating staff and families, but specific interventions for the resident in question were lacking.
Infection Control Deficiencies in Peri-Care Practices
Penalty
Summary
The provider failed to ensure proper infection prevention and control practices during peri-care and incontinence care for residents. Observations revealed that three certified nurse aides (CNAs) did not adhere to hand hygiene and glove use protocols while assisting residents with toileting and peri-care. Specifically, CNAs were observed reusing soiled wipes, failing to change gloves between dirty and clean procedures, and not assisting residents with hand hygiene after toileting. In one instance, CNA L used unclean gloves to handle wipes and assist another CNA in cleaning a resident's peri-area, while CNA K reused a soiled wipe for the same resident. Additionally, the resident was not assisted with hand hygiene after toileting. Another observation showed CNA I using the same soiled wipe to clean a resident's peri-area from back to front, and then handling clean incontinence briefs with contaminated gloves. Similar practices were noted with another resident, where CNA I did not sanitize her hands after removing gloves and before touching various items in the resident's room. Interviews with the CNAs and the Director of Nursing/Infection Preventionist (DON/IP) revealed that the staff were aware of the correct procedures but failed to implement them consistently. The facility's policies on peri-care and hand hygiene were reviewed, highlighting gaps in practice, such as not including hand hygiene before applying clean gloves. Despite previous training and audits, the CNAs did not follow the expected protocols during the observed incidents.
Deficiency in Mechanical Lift Usage
Penalty
Summary
The facility was found to have a deficiency related to the use of mechanical lifts for resident transfers. The deficiency was identified through a review of records, staff interviews, and resident interviews. It was revealed that the facility had not initially ensured that all nursing staff were properly educated and competent in using mechanical lifts, which led to improper transfers. Observations confirmed that staff did not perform transfers with the mechanical lift correctly, which could have compromised resident safety.
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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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Nursing homes near Sturgis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spearfish Canyon Healthcare | 17.9 mi | ★★★★★ | 13 | 0 |
| Good Samaritan Society - St Martin Village | 23 mi | ★★★★★ | 3 | 0 |
| Rolling Hills Healthcare | 23.6 mi | ★★★★★ | 12 | 0 |
| Fountain Springs Healthcare | 24.3 mi | ★★★★★ | 11 | 0 |
| Avantara North | 25.1 mi | ★★★★★ | 2 | 0 |
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