Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Platte Care Center during CMS and state inspections, most recent first.
A CNA who primarily worked in activities returned a resident to his room in a wheelchair and left him alone, despite the resident’s pocket care plan clearly stating in bold that he must not be left unattended in his wheelchair in his room. The CNA, a newer staff member, had the pocket care plan but did not review it and was unaware of this restriction. While alone, the resident attempted to adjust his pants and transfer toward the toilet, his right leg gave out, and he slid down onto the wheelchair foot pedals, then used the bathroom call light for help. He reported severe right leg pain and inability to bear weight, was evaluated in the ED with no fractures found, and received additional pain management orders afterward.
A resident with late onset dementia was started on a psychotropic medication at the request of their POA, but the facility failed to obtain and document signed informed consent prior to administration. Although verbal education was provided, no consent form was signed or included in the medical record, and the facility's policy did not address informed consent requirements.
A resident with severe cognitive impairment eloped from the facility after a staff member failed to check outside when a door alarm sounded, and two CNAs did not follow a care plan requiring two-person transfers and proper use of equipment for a resident with multiple medical conditions. Not all staff received updated training on elopement or transfer procedures, and care plans lacked clear interventions.
A resident was found in a soiled brief, despite documentation by a CNA indicating it had been changed. Multiple staff reported the CNA's neglectful behavior, but no action was taken. The administrator expected such allegations to be reported to the SD DOH, but staff did not utilize the online reporting system, highlighting a deficiency in the facility's adherence to its zero-tolerance policy for neglect.
A resident was allegedly neglected by a CNA who failed to change their incontinence brief as documented. Despite multiple reports from staff about the CNA's neglectful behavior, the facility's administrator was unaware of any written reports, and the director of nursing did not properly address the allegations. The facility's policy requires thorough investigation of alleged violations, but the process for reporting neglect was inadequately documented.
A resident with intact cognition reported that a CNA insinuated she was being recorded during care, which the CNA admitted to doing to make the resident believe she was being recorded. The incident was reported to the facility administrator, and the CNA was reassigned for the night. The resident had previous unreported issues with the CNA.
The facility failed to properly monitor and document dishwasher temperatures, crucial for sanitizing dishes used for residents' meals. Observations and record reviews showed multiple instances of out-of-range temperatures without corrective actions. Interviews with staff revealed a lack of adherence to the facility's policy on temperature monitoring, contributing to the deficiency.
The facility did not ensure that the posted daily staff data accurately reflected the actual hours worked by CNAs. The staff hours posting form included pre-printed scheduled hours but was not updated to reflect actual hours worked. Interviews revealed that the CNA section of the form was not updated, and staff were unaware that the posted hours should reflect actual hours worked.
Resident Left Unattended in Wheelchair Contrary to Care Plan, Resulting in Fall
Penalty
Summary
The deficiency involves a failure to ensure a resident’s care plan was followed to prevent accidents. A certified nursing assistant (CNA) who primarily worked in activities transported a resident back to his room in a wheelchair after an activity and left him alone in the room with his call light within reach. The resident’s pocket care plan, which the CNA had but did not read, clearly stated in bold print that he could not be left alone in his wheelchair in his room. At the time, the CNA was a newer employee who had recently passed her CNA test and did not usually work CNA shifts, and she reported she was not aware of the resident’s care plan requirement that he not be left unattended. After being left alone, the resident attempted to adjust his pants and transferred himself toward the toilet. During this attempt, his right leg gave out, and he slid down in his wheelchair onto the foot pedals. He then pulled the bathroom call light for assistance. When staff responded, he reported increased pain in his right leg and an inability to bear weight on that leg. He rated his pain as 10 out of 10 and was subsequently sent to the emergency department for evaluation. At the emergency department, X‑rays of the resident’s right thigh and pelvis showed no acute findings, meaning there were no fractures. Following his return, additional pain control measures were ordered, including PRN acetaminophen, topical diclofenac gel, and a lidocaine patch for his right thigh. The resident used the lidocaine patch daily until it was discontinued at his request several days later. Later review of his pocket care plan showed the instruction “DO NOT LEAVE ALONE IN WHEELCHAIR IN HIS ROOM!!!!!” in bold letters, confirming that the resident-specific fall prevention intervention was in place but not followed at the time of the incident.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document informed consent for the administration of a psychotropic medication to a resident diagnosed with hallucinations due to late onset dementia. The resident’s daughter, who held power of attorney, requested medication to address the resident’s increasing behaviors, resulting in an order for Quetiapine Fumarate (Seroquel) to be administered at bedtime. Although the care plan indicated that the family would be informed of the risks and benefits of psychotropic medication, and that consent should be obtained, there was no documentation in the electronic medical record that informed consent was provided to or signed by the resident’s daughter/POA prior to starting the medication. Interviews with facility staff, including the social worker, DON, and administrator, confirmed that while verbal education regarding the risks and benefits was provided, no signed consent form was obtained or scanned into the resident’s record. The facility had an existing consent form available at the time the medication was initiated, but it was not utilized. Additionally, the facility’s psychoactive drug monitoring policy did not reference the requirement for risk/benefit education or informed consent for residents or families.
Failure to Prevent Elopement and Ensure Safe Transfers Due to Inadequate Supervision and Noncompliance with Care Plans
Penalty
Summary
The facility failed to ensure resident safety by not providing adequate supervision and not following established care plans, resulting in two significant incidents. In the first incident, a resident with severe cognitive impairment, dementia, and a high risk for falls exited the building unsupervised through an alarmed door. The social worker, upon hearing the alarm, reset it and looked down the hallway but did not check the outside area. The resident remained outside for approximately five minutes before being brought back inside after another resident notified the social worker. The resident's care plan was updated after the incident to reflect elopement risk, but the pocket care plan did not list specific interventions to prevent elopement. Additionally, not all staff received education regarding elopement procedures following the incident, and the facility's policy did not specify that staff should check outside when a door alarm sounds. In the second incident, two certified nursing assistants (CNAs) did not follow the care plan for a resident with multiple medical conditions, including a history of falls, chronic pain, and Parkinson's disease. The care plan required that the resident be transferred with the assistance of two staff members, a gait belt, and a walker, or with one to two staff using a sit-to-stand lift. Observations revealed that one CNA assisted the resident alone using a stand and pivot transfer without a gait belt, and another CNA used a sit-to-stand lift without securing the resident's lower legs and without a second staff member. The CNAs determined the level of assistance based on their judgment rather than following the care plan, and the pocket care plan did not provide clear instructions for staff. The facility's policies required annual in-services on correct lifting and transferring procedures, including the use of gait belts and mechanical lifts. However, documentation showed that not all staff, including contracted and dietary staff, had received updated training or education on these procedures after the incidents. There was also no plan in place for monitoring or auditing compliance with elopement prevention or transfer procedures.
Failure to Report Suspected Neglect
Penalty
Summary
The provider failed to report suspected neglect for a resident, as evidenced by an anonymous complaint filed with the South Dakota Department of Health. The complaint detailed an incident where a resident was found in a soiled brief, despite documentation by CNA D indicating the brief had been changed earlier. The complaint also noted that night shift staff had previously reported CNA D's neglectful behavior, but no changes were made to address these concerns. Additionally, LPN C was informed by another CNA that CNA D was not completing required checks on residents and was falsely documenting her actions. When confronted, CNA D threatened LPN C, and despite multiple complaints from staff, the allegations were not reported to the appropriate authorities. Interviews with staff revealed a culture of fear regarding retaliation from management, with several staff members having reported CNA D's neglect to the DON and administrator without any subsequent action. The administrator acknowledged that neglect constituted a failure to provide necessary care and expected such allegations to be reported to the SD DOH. However, despite awareness of the online reporting system, staff did not report the neglect allegations, instead relying on internal reporting to the DON. The facility's policy emphasized a zero-tolerance approach to abuse and neglect, yet the failure to report and investigate these allegations indicates a deficiency in adhering to this policy.
Failure to Investigate Allegations of Neglect
Penalty
Summary
The provider failed to thoroughly investigate allegations of neglect involving a resident and a certified nursing aide (CNA). An anonymous complaint was made to the South Dakota Department of Health (SD DOH) regarding the neglect of a resident by CNA D, who was accused of not changing the resident's incontinence brief as documented. The complaint indicated that the brief was not changed at the time reported by CNA D, and there were multiple reports from night shift staff about CNA D's neglectful behavior that did not result in any change. The facility's administrator was unaware of any written reports of neglect allegations, despite a corrective action plan form being submitted by a licensed practical nurse (LPN) regarding the suspected neglect. The facility's director of nursing (DON) was on vacation when the corrective action plan form was placed on her desk, and upon her return, she interviewed CNA D, who denied the allegations. The DON considered the matter settled after CNA D apologized to LPN C for a confrontation. The facility's policy requires thorough investigation of all alleged violations and prevention of further potential abuse during investigations, but the process for reporting neglect was inadequately documented, and the allegations were not properly addressed or reported to the SD DOH as expected.
Failure to Protect Resident from Mental Abuse by CNA
Penalty
Summary
The provider failed to protect a resident from abuse by a certified nursing assistant (CNA) who insinuated she was videoing the resident while providing care. The resident, who had an intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15, reported the incident to a licensed practical nurse (LPN). The CNA admitted to making the resident believe she was being recorded, although she was not actually recording. This incident was reported to the facility administrator, and the CNA was reassigned to a different hallway for the remainder of the night. The resident had previous issues with the CNA but had not reported them before this incident. The CNA had undergone a background check with no prior abuse allegations and had completed education on abuse both prior to hiring and during orientation. The incident was reported to the CNA's agency and law enforcement was notified. The facility's failure to protect the resident from this form of mental abuse constitutes a deficiency in their duty to safeguard residents from abuse.
Failure to Monitor and Document Dishwasher Temperatures
Penalty
Summary
The provider failed to ensure proper monitoring and documentation of dishwasher temperatures, which are crucial for the cleaning and sanitization of dishes used to serve residents' food. Observations revealed that the dishwasher temperatures were not consistently recorded, and there were instances where the wash cycle temperatures were below the required range. Specifically, on multiple occasions, the wash cycle temperatures were documented as being out of range, yet there were no documented interventions to address these discrepancies. The review of temperature logs from September to November showed numerous missed opportunities for temperature documentation and several instances of out-of-range temperatures without any corrective actions noted. Interviews with staff, including the dishwasher operator, dietary manager, and administrator, highlighted a lack of adherence to the facility's policy on dishwasher temperature monitoring. The dietary manager, who was new to the position, had not reviewed the dishwasher policy or the temperature documentation. The administrator acknowledged the failure to document interventions for out-of-range temperatures and mentioned that a performance improvement plan had been developed but not implemented. The facility's policy required daily checks and recordings of appropriate sanitation levels, which were not consistently followed, leading to the deficiency.
Inaccurate Posting of CNA Hours
Penalty
Summary
The facility failed to ensure that the posted daily staff data accurately reflected the actual hours worked by certified nursing assistants (CNAs). During an observation, it was noted that the staff hours posting form, located in the front entrance hallway, included pre-printed scheduled hours for licensed nurses and CNAs but did not reflect the actual hours worked by CNAs. Interviews with a CNA, the director of nursing, and the administrator revealed that the CNA section of the form was not updated to include any changes in hours worked, and they were unaware that the posted hours should reflect actual hours worked. The scheduled hours for licensed nurses were reported to be accurate, but the discrepancy was specifically with the CNA hours.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 3 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 Platte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society Corsica | 21.8 mi | — | 0 | 0 |
| Lake Andes Senior Living | 21.9 mi | ★★★★★ | 3 | 0 |
| Aurora Brule Nursing Home Inc | 24.3 mi | ★★★★★ | 0 | 0 |
| Avera Rosebud Country Care Center | 31.3 mi | ★★★★★ | 5 | 0 |
| Butte Senior Living | 32.4 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Platte Care Center.
100% money-back within 48 hours.
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.