Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sanford Chamberlain Care Center during CMS and state inspections, most recent first.
Failure to supervise residents at risk for elopement led to multiple incidents involving a resident who crawled out a window and two residents who left the facility without adequate oversight. One resident with significant behavioral and psychiatric diagnoses exited through a window and was later found walking away from the building, while another resident with moderately impaired cognition was allowed outside to smoke and did not return. A third resident with severe cognitive impairment was found outside after leaving through an unsecured main entrance, and survey observations also showed residents smoking outside without staff present despite posted supervision requirements.
Medication administration errors exceeded the allowed rate after a CMA left Seroquel at a resident’s bedside without watching the dose taken, another CMA left a resident alone with a nebulizer treatment without a self-administration order, an RN removed an insulin pen before the full dose was delivered, and a resident’s calcium/vitamin D/vitamin K blister pack label did not match the MAR. The residents involved had varying cognitive status and diagnoses, and the facility’s own policy required medication error rates of 5% or less and proper self-administration orders and matching medication labels.
A CMA left medication at the bedside for two residents without confirming self-administration orders or staying to watch the doses be taken. One resident had an intact BIMS and a self-administration assessment that limited her to certain topical and nasal meds, while the other resident had an intact BIMS and orders for nebulized medication with no self-administration instructions. The DON stated that self-administration required an assessment and provider order, and that staff should remain with the resident until the medication was fully taken.
Damaged Bathroom Flooring Not Maintained: A resident’s bathroom flooring had a large gouge with curled edges, creating an uneven surface. The resident had dementia, a BIMS score of 3, needed 2-staff assist for transfers, and had a history of falls. The interim administrator, DON, POS, and CNA all identified the torn flooring as a fall hazard and an uncleanable surface, but the POS had not been aware of the damage.
PASRR screening was not completed as required for two residents with mental health and cognitive-related diagnoses. One resident had bipolar disorder, PTSD, and depression with a BIMS score indicating intact cognition, but her PASRR Level I review expired because the required paperwork was not completed in time. Another resident had severe cognitive impairment with diagnoses including neurocognitive disorder, psychotic disorder, and intellectual disabilities, and her PASRR Level II paperwork was not submitted until the survey team requested it.
Care plans were not updated to reflect the current needs of two residents. One resident with severe cognitive impairment, dysphagia, and weight loss had a care plan that did not include her ordered diet, meal encouragement interventions, or supplements discussed in care conference and nutrition notes. Another resident with moderately impaired cognition and cerebral palsy was observed smoking alone outside, but his care plan did not identify him as a smoker or include the smoking assessment and related safety information. Interviews with the MDS coordinator and DON confirmed these items were expected to be included in the care plan.
Oxygen tubing was not managed consistently for two residents receiving O2. Staff observed tubing dated with expiration dates instead of the weekly change date, and an RN and DON stated tubing should be changed weekly and dated at that time. One resident also lacked a provider order for O2, and the facility policy required O2 only with a medical provider order and disposable equipment changed weekly or per manufacturer instructions with date and initials.
A resident with severe cognitive impairment and multiple psychiatric and GI diagnoses had significant unplanned weight loss, dropping 10.04% in 90 days and 12.64% in 180 days. She was observed sleeping through the day and refusing meals, and the record showed ongoing poor intake, supplement refusal, and weight fluctuations, but no documentation was provided showing that the physician was notified of the significant weight loss.
A resident did not receive the full ordered dose of insulin when an RN removed the insulin pen too soon and insulin expelled onto the resident’s skin. The RN said she normally waits three seconds before removing the pen, and the DON stated that failure to give the full dose, notify the provider, and increase monitoring was a significant medication error. Another resident’s calcium/vitamin D3/vitamin K blister packs did not match the physician’s order in the EMR, and the CMA acknowledged the mismatch.
A cook repeatedly handled resident meals, utensils, condiment bottles, refrigerator and cupboard doors, and meal tickets with the same gloves while plating and serving food. She also removed and replaced gloves without washing her hands and continued serving breakfast items, beverages, and dirty dishes without proper hand hygiene between tasks. The dietary manager said staff were expected to change gloves and wash hands between tasks, and the facility policies required glove changes and hand washing during food prep and meal delivery.
Call Light Not Available to Resident After Therapeutic Leave: A resident recovering from alcohol use and bilateral hip fractures was observed without a call light in reach after returning from therapeutic leave. The call light was not plugged in near his bed during multiple observations, and a CMA stated it had not been reconnected after room flooring work. An RN acknowledged residents should have a call light in reach at all times, and the facility policy stated residents always had a method to call for assistance.
A resident with multiple chronic wounds, diabetes, PVD, MRSA, edema, and pain left the facility for therapeutic leave home visits without a physician order for the leave, without a care plan entry for the leave, and without an order for a return assessment. Staff stated his medications were not sent, and wound supplies were likely not sent either, despite the resident requiring extensive wound care and dressing changes. The DON confirmed the lack of a therapeutic leave order and said wound supplies should have been sent, while the MDS coordinator stated the leave was not addressed on the care plan.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident with severe cognitive impairment experienced multiple falls and was handled roughly and restrained by a CNA, who failed to notify a nurse or request assistance. Several staff members, including an LPN and other support staff, witnessed the incidents but did not intervene or report the abuse. The resident was not assessed after the falls, and staff failed to follow required protocols. Training records showed that many staff had not received abuse and neglect education, and facility policy on reporting abuse was not followed.
Two residents with severe cognitive impairment and a history of falls experienced repeated falls, including one resulting in a hip fracture, due to the facility's failure to update care plans and implement new fall prevention interventions after each incident. Staff did not consistently document or apply new strategies, and there was confusion about where to find or how to update fall interventions in the EMR, despite management expectations and facility policy.
Two residents with severe cognitive impairment experienced multiple changes in condition, including repeated falls and changes in transfer and hospice status, but their care plans were not updated to reflect new interventions or current needs. Staff interviews revealed inconsistent understanding of care plan responsibilities, and documentation showed that required updates and interventions were often missing or incomplete.
A facility failed to implement an action plan after a resident with cognitive impairment became aggressive, striking another resident. Staff lacked adequate training to manage dementia-related behaviors, relying on online courses without hands-on training. Additionally, there was insufficient communication of care plan updates, leaving staff unprepared to handle the resident's unpredictable behavior.
A resident fell and suffered head trauma while attempting to sit on a whirlpool chair due to the brakes not being locked by a CNA. The resident, who had a history of falls and required supervision for bathing, sustained injuries and required emergency room treatment. The CNA had been trained on safety measures, but there was no signage in the tub room about locking the chair wheels, and the manufacturer's instructions were not readily available.
A resident with severe cognitive impairment and a history of dehydration was found to have inadequate fluid intake, leading to dehydration and a urinary tract infection. Despite water being available, fluid intake was not consistently documented, and the resident's intake was significantly below recommended levels. The resident also experienced significant weight fluctuations, with no follow-up on documented weight loss, highlighting a deficiency in care.
A resident with severe cognitive impairment and a history of frequent falls did not receive the required neurological checks after a fall, as per the facility's policy. The resident, who had multiple diagnoses including Tourette's and prostate cancer, was later diagnosed with rib fractures, a UTI, and dehydration. The facility's policy mandated specific neurological checks following unwitnessed falls, which were not documented as completed.
A resident with a history of trauma expressed fear and suicidal thoughts after an unwanted entry into her room by another resident with cognitive impairment. The facility failed to implement adequate interventions to prevent further incidents. Additionally, two residents engaged in repeated verbal and physical altercations, with insufficient interventions to prevent these incidents. The facility's abuse prevention policies were not effectively implemented, contributing to the deficiency.
A facility failed to conduct required trauma screenings for residents, including one with a history of PTSD and recent psychiatric hospitalization. The licensed social worker confirmed the screenings were not completed as required by the facility's trauma-informed care policy. Additionally, the DON did not review hospital notes for a resident returning from psychiatric care.
The facility failed to update care plans for several residents, leading to deficiencies in care. A resident fell during a transfer due to outdated care plan instructions, while another resident's care plan did not address his wandering and aggressive behavior. Additionally, a resident with PTSD and recent psychiatric hospitalization had an incomplete care plan, lacking details on her mental health needs and safety plan.
A resident with dementia and Alzheimer's disease eloped from the facility and fell, requiring emergency evaluation. Despite wearing a Wander Guard, the resident exited through the front doors without staff knowledge. The facility's interventions, including monitoring and the Wander Guard, were insufficient to prevent the incident. Staff were alerted by a passerby, but the resident had already sustained injuries. The care plan lacked specific boundaries for safe wandering, and the facility's policy required an incident report and care plan revision after elopement.
The facility failed to maintain food safety and cleanliness in two kitchenettes, with observations of unclean refrigerators, unlabeled food items, and dirty kitchen surfaces. Staff interviews revealed a lack of awareness and responsibility for cleaning and maintenance, with inconsistencies in following cleaning checklists and policies. The dietary department, responsible for these tasks, did not ensure proper labeling and dating of food items, contributing to the deficiency.
A resident with dementia and Alzheimer's disease eloped from the facility on three occasions, but two incidents were not reported to the South Dakota Department of Health as required. The Director of Nursing and the Director of Nursing Trainer initially misinterpreted these incidents as non-elopements. Upon review, it was confirmed that these incidents should have been reported, as per the facility's policy.
A resident at risk for skin injuries developed a wound on the left buttock, which was not promptly assessed or reported to the physician. The facility failed to conduct weekly skin assessments and document the wound's status, leading to inconsistencies in care. Nursing staff interviews revealed confusion in the skin assessment process, and the facility's policy on skin breakdown prevention was not effectively implemented.
Failure to Supervise Residents at Risk for Elopement
Penalty
Summary
The facility failed to keep residents at risk for elopement safe when resident 22 crawled out of a window and left the building without staff knowledge, and when residents 51 and 52 exited the facility without adequate supervision. Resident 22 had diagnoses including epilepsy, anxiety disorder, borderline personality disorder, PTSD, bipolar disorder, alcohol abuse, and weakness, and her care plan identified a history of attempts to elope from the facility and on outings. On 11/26/25, she was observed outside the building after removing a window screen and opening the window in her room. Staff later found her walking away from the facility toward a church one block away, and police were notified after she had already left the building. During the elopement event, staff searched for resident 22 after she was reported missing, and she was eventually located outside the facility in cold weather. She was wearing multiple layers of clothing and was taken to the ER for evaluation before returning to the facility. Interviews showed that the window in her room could be opened outward, and the screen had been removed. Staff also reported that window handles were removed after the incident, and a lock block and chains were later added to limit how far the window could open. The record also showed that resident 22 had been identified in her care plan as not to be left at appointments due to her risk for leaving and that outings required family approval. Resident 51, who had moderately impaired cognition and diagnoses including nicotine dependence and alcohol use, was allowed to smoke outside and had been approved to go out unsupervised to smoke. On 9/5/25, he was let out to smoke and later found missing after he did not return. The facility initiated its elopement protocol, searched the building and surrounding area, and notified police, but resident 51 was not returned to the facility. Resident 52, who had severe cognitive impairment from Lewy body dementia and required supervision around the facility due to high fall and elopement risk, was found outside the facility on 2/5/26 even though he had not previously been identified as an elopement risk and was not wearing a WanderGuard. The main entrance door was unlocked and not alarmed at the time, and his care plan was updated only after he was found outside. Observations during the survey also showed residents smoking outside without staff present, despite posted smoking times and signage stating residents must be observed by staff while outside smoking.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent. Survey observations, interviews, record review, and policy review identified multiple medication administration errors involving resident self-administration, insulin administration, and a mislabeled medication card. The observed errors resulted in a medication error rate of 14.29%. Resident 24, whose BIMS score was 14 and whose diagnoses included anxiety, PTSD, epilepsy, weakness, and chronic pain, was observed with Seroquel 50 mg left in a medicine cup on the bedside table by a CMA, who did not watch the resident take the medication. The resident’s record showed an order for Seroquel 50 mg once daily with no special instructions for self-administration. Although the resident had orders allowing self-administration of certain topical and nasal medications, her self-administration assessment stated she did not want to administer pill forms and had difficulty with her left arm and weak hand grip. Resident 37, whose BIMS score was 15 and whose diagnoses included COPD, hemiplegia, presbyopia, emphysema, dysphagia, and aphasia, was observed receiving Ipratropium-Albuterol nebulizer medication from a CMA who then left the room after turning on the machine. The resident had orders allowing self-administration of eye drops and an inhaler, but no order for self-administration of the nebulizer medication. Resident 36, whose BIMS score was 10 and whose diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy, chronic kidney disease stage 3, hypo-osmolality, hyponatremia, chronic systolic heart failure, rheumatic mitral stenosis, nonrheumatic mitral insufficiency, and pulmonary hypertension, was observed receiving Novolog FlexPen insulin. The RN removed the pen from the resident’s abdomen before the dose was fully dispensed, and insulin was seen expelling onto the resident’s skin. Resident 38, whose BIMS score was 12 and whose diagnoses included weakness, age-related osteoporosis without current pathological fracture, and chronic kidney disease stage 3, was observed with morning calcium/vitamin D/vitamin K blister packs labeled differently than the physician’s order in the EMR. The CMA acknowledged the mismatch between the blister pack label and the order, and the DON confirmed the label was incorrect.
Failure to Verify Self-Administration Orders Before Leaving Medications at Bedside
Penalty
Summary
The provider failed to ensure that evaluations for self-administration of medication were completed for two residents whose medications were left at the bedside by a CMA. During observation, the CMA left Seroquel 50 mg in a medicine cup on one resident’s bedside table and did not watch her take it. In a separate observation, the CMA placed Ipratropium-Albuterol nebulizer medication into another resident’s nebulizer machine and then left the room after the resident turned the machine on. One resident had an intact BIMS score of 14 and diagnoses including anxiety, PTSD, epilepsy, weakness, and chronic pain. Her MAR showed an order for Seroquel 50 mg once daily with no special instructions for self-administration. Although she had a self-administration assessment and an order allowing her to self-administer several topical and nasal medications, that assessment specifically stated she did not want to administer pill forms because she might spill, drop, or mess up, and she had left arm ROM limitations and weak hand grip. The other resident had an intact BIMS score of 15 and diagnoses including COPD, hemiplegia affecting the right dominant side, presbyopia, emphysema, dysphagia, and aphasia. His MAR showed an order for Ipratropium-Albuterol nebulizer solution with no special instructions for self-administration. He did have older orders allowing self-administration of Refresh Optive eye drops and a ProAir HFA inhaler. The DON stated that residents were expected to have a self-administration assessment and provider order before medications were left with them, that self-administration orders would be listed in special instructions, and that staff should stay with residents until the medication was taken completely.
Damaged Bathroom Flooring Not Maintained
Penalty
Summary
The provider failed to maintain resident bathrooms in a clean and well-kept condition free from damaged flooring for one sampled resident. During observation, the resident’s bathroom had a gouge in the flooring near the wall that measured approximately 12 inches long by one inch wide, and the flooring curled up around the edges, creating an uneven surface. The resident had been admitted to the facility with unspecified dementia and had a BIMS score of 3, indicating severe cognitive impairment. The resident’s care plan showed she required assistance from two staff members for transfers to and from the toilet, bed, recliner, wheelchair, and bath chair, used her feet to propel her wheelchair, and had a history of falling. Interviews with the interim administrator, DON, plant operations supervisor, and CNA confirmed the damaged flooring was considered a fall hazard and an uncleanable surface, but the plant operations supervisor had not been aware of the damage. The facility’s Assets Resource Packet stated that assets should be repaired or replaced if they did not meet code or safety standards.
PASRR Screening Not Completed for Two Residents
Penalty
Summary
PASRR screening was not completed as required for two sampled residents with mental health or cognitive-related diagnoses. Resident 22 was admitted with diagnoses including bipolar disorder, PTSD, and depression, and her BIMS score was 14, indicating she was cognitively intact. Her record included a DSS letter approving her for 365 days for admission or continued stay, and a PASRR resident review noted serious mental illness and referred her to Maximus for resident review. Maximus later issued a notice stating the resident’s PASRR Level I review determination had expired because the required Level I screening form and/or documentation were not completed within the required timeframe. During interviews, the LSW stated she completed the PASRR paperwork for the facility and had received the expiration letter for resident 22, but she had not received the expected determination letter back from Maximus. She later stated Maximus wanted the Level I paperwork resubmitted and that she was unsure why the paperwork had not been received in 2024. The DON stated she expected the LSW to complete and submit the PASRR Level I forms and resident reviews and to handle any recommendations made for residents. Resident 2 was admitted with a BIMS score of 0, indicating severe cognitive impairment, and diagnoses including mild neurocognitive disorder with behavioral disturbances, psychotic disorder, unspecified disorder of adult personality and behavior, and unspecified intellectual disabilities. Her DHS letter approved continued staff-provided services for 120 days and recommended continued therapy or restorative nursing services and a psychological evaluation with full-scale IQ and adaptive testing. The PASRR Level II paperwork for resident 2 was not submitted until the survey team requested it, and the LSW stated it should have been completed before the approved days expired.
Care plans did not reflect current smoking status and nutritional needs
Penalty
Summary
The facility failed to ensure resident care plans were revised to reflect current needs for two residents. One resident had a care plan that did not identify her dysphagia diet order, did not include interventions for staff to encourage her to get up and attend meals, and did not include the supplements discussed in care conference and nutritional notes, including Magic Cup or the proposed peanut butter cup therapy. She was observed sleeping in bed during the day, refused breakfast and lunch, and was later seen waking up and remaining in bed in the dark. Her record showed severe cognitive impairment, multiple psychiatric and medical diagnoses, and a physician order for a soft diet with thin liquids. The second resident was observed outside in a wheelchair smoking alone near the street. His record showed moderately impaired cognition, cerebral palsy, chronic pain, and anxiety disorder. A smoking assessment in the record indicated he could wheel himself to the designated smoking area, light and smoke a cigarette safely, extinguish it, and dispose of the butt appropriately. However, his care plan did not identify him as a smoker, did not show that a smoking assessment had been completed, and did not include that he was safe to smoke independently. Interviews confirmed that care plans were expected to be updated with changes and that smoking information and precautions should be included when applicable. The DON stated she expected smoking to be on the care plan, along with the smoking assessment and any precautions. She also stated she expected the care plan for the other resident to include interventions to encourage meal attendance and the supplements to be given. The provider’s care plan policy stated each resident would have an individualized, person-centered, comprehensive plan of care addressing identified needs through assessments and physician orders.
Oxygen Tubing Not Dated or Changed Consistently
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured when two of two sampled residents, 21 and 37, had oxygen tubing that was not dated in a way that matched the facility’s weekly change expectations. Observation showed resident 21’s oxygen tubing was dated with the expiration date rather than the date it was changed, and resident 37’s tubing was also dated with the expiration date instead of the weekly change date. During interview, the RN stated the tubing should be changed weekly and dated at that time, not the date it expired. Review of resident 37’s electronic medical record showed the oxygen tubing had been changed weekly, but the dates on the tubing did not match those records. Resident 21 also did not have a physician’s medical order to administer oxygen. The DON stated she expected oxygen tubing to be changed weekly and dated at that time, and the facility’s oxygen administration policy required oxygen to be used only with a medical provider order and disposable equipment to be changed weekly or per manufacturer instructions and marked with date and initials.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The provider failed to notify the physician of one resident who had unplanned significant weight loss. The resident had severe cognitive impairment with a BIMS score of 0 and diagnoses including mild neurocognitive disorder with behavioral disturbances, psychotic disorder, unspecified disorder of adult personality and behavior, unspecified intellectual disabilities, depression, non-infective gastroenteritis and colitis, and gastric ulcer without hemorrhage or perforation. Her weight decreased from 134.5 lbs on 4/12/26 to 121 lbs on 7/12/26, a 10.04% loss in 90 days, and from 138.5 lbs on 1/12/26 to 121 lbs on 7/12/26, a 12.64% loss in 180 days. The resident was observed asleep in bed during the day and was reported by CNA to have refused breakfast and lunch. She was later observed waking up but still lying in bed in the dark, and RN J later documented that the resident refused lunch again when awakened for medications. The record also showed repeated weight fluctuations and ongoing nutritional concerns, including refusal of supplements and picky eating discussed at a care conference. The DON stated that nursing staff would notify a physician if there was a 4 lb difference in weight, but no documentation was produced showing that the physician was notified about the resident's significant weight loss.
Significant Medication Errors With Insulin and Mismatched Medication Labeling
Penalty
Summary
Resident 36 did not receive her full ordered dose of Novolog FlexPen insulin when RN J administered the medication and removed the pen from the injection site too soon. During observation, the insulin was injected into the resident’s abdomen, but the pen was pulled away after about one second, and insulin was seen expelling onto the resident’s skin. The resident’s MAR showed an order for Novolog FlexPen U-100 insulin 5 units subcutaneously with meals at 8:30 a.m., 12:00 p.m., and 5:30 p.m. Her record also showed diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, chronic kidney disease stage 3, hypo-osmolality, hyponatremia, chronic systolic heart failure, rheumatic mitral stenosis, nonrheumatic mitral insufficiency, and pulmonary hypertension. Her BIMS score was 10, indicating moderately impaired cognition. RN J stated that her process for insulin administration was to wait three seconds before removing the insulin pen to ensure the resident receives the full dose. She agreed that if insulin was expelled onto the resident’s skin when the needle was removed, the resident did not receive the full ordered dose. She also stated that if the resident did not get the full dose, she would tell the DON, monitor the patient, and notify the provider. The DON later stated that a resident not receiving the full ordered dose of insulin, the physician not being notified, and the lack of increased monitoring after the medication error were considered a significant medication error. Resident 38 also experienced a medication administration issue when CMA H prepared to give a morning dose of calcium/vitamin D3/vitamin K from blister packs whose label did not match the physician’s order in the EMR. The blister packs were labeled as LDR Vit C600+D3/MINS CHEW, while the order in the record was for Calcium 500 mg-Vitamin D3 1000 u-Vitamin K 40 mcg chewable tablet, 1 tablet twice daily. CMA H acknowledged that the label and the physician’s order did not match, and the DON stated that the medication cards were expected to match the MAR. The medication blister packs remained in the medication cart later that day.
Failure to Perform Hand Hygiene and Change Gloves During Meal Service
Penalty
Summary
Food service staff failed to perform appropriate hand hygiene and glove changes while preparing and serving resident meals. During the noon meal service, cook Q was observed plating multiple resident meals while wearing the same gloves and using those gloves to handle buns, serving utensils, plates, bowls, condiment bottles, refrigerator and cupboard doors, and meal tickets. She also wrote on resident meal tickets with one gloved hand while continuing to handle food and serving items with the other, and at one point removed her gloves and put on a new pair without washing her hands. She later told CNA L that she could not put ketchup and mustard on a plate because she had gloves on, and CNA L applied the condiments instead. The same cook was later observed frying eggs and preparing breakfast items while wearing gloves, then removing and replacing gloves without performing hand hygiene. She moved between the stove, refrigerator, cupboards, microwave, serving cart, and dining room while continuing to handle bowls, trays, silverware, milk, juice glasses, oatmeal, and other food items. She also handled glasses by the rim and continued serving residents while wearing the same gloves. At one point she removed her gloves, washed her hands, and then served a can of pop, coffee, and dirty dishes without wearing gloves or washing her hands between tasks. The dietary manager stated that staff were expected to change gloves and perform hand hygiene between each task and should not use gloved hands to pick up buns while also handling utensils or opening refrigerator or cupboard doors. Cook Q stated she usually worked in the main kitchen, was filling in for a dietary aide, wore gloves most of the time because of a recently ruptured cyst on her finger, and believed that as long as she did not touch food she did not have to change her gloves. The facility’s hand washing and glove use policy required single-task glove use, hand washing after touching contaminated objects, before and after using gloves, and between dirty and clean dish handling, and its meal service policy required proper hand washing or glove changes during plating and delivery of resident meals.
Call Light Not Available to Resident After Therapeutic Leave
Penalty
Summary
The provider failed to ensure that resident 17 had a call light in reach after returning from therapeutic leave. On 7/14/26, the resident was observed in bed with no call light within reach and no call light plugged into the wall outlet; he stated he was recuperating from drinking and fractures to both hips and said he could get up and walk around and did not need a call light. On 7/15/26 and 7/16/26, the resident was not in his room and there was still no call light plugged into the wall outlet near his bed. A CMA stated the resident had been on therapeutic leave from 7/10/26 to 7/13/26 while his room was updated with new flooring, the room had been cleared out, items were brought back, and the call light near the bed was not plugged back in after his return on 7/13/26. An RN stated she was not aware the resident had not had his call light in reach since returning and acknowledged residents should have a call light in reach for assistance at all times. The facility policy stated residents always had a method of calling for assistance.
Therapeutic Leave Lacked Orders and Needed Supplies Were Not Sent
Penalty
Summary
The facility failed to have physician orders for therapeutic leave for one sampled resident who routinely left the facility for home visits. Resident 33 was his own decision-maker and used a wheelchair for mobility. His record showed multiple diagnoses, including pressure ulcer of the sacral region, diabetes mellitus with foot ulcer, peripheral vascular disease, osteomyelitis of the vertebra and sacrococcygeal region, MRSA infection, localized edema, pain, and shortness of breath. The record also showed no physician order to complete a head-to-toe assessment when he returned from therapeutic leave, no physician order for the therapeutic leave home visits, and no care plan addressing therapeutic leave. Resident 33 had physician orders for multiple medications and extensive wound and skin treatments, including diabetic foot and nail care, compression devices, heel lift boots, Santyl to several wounds, Dakin's solution, wound cleansing, dressings, and edema care. The LPN stated the resident would leave for therapeutic leave home visits and that briefs and extra clothes were sent with him, but she did not think wound supplies were sent and said medications were not sent because there was no physician order to do so. She also stated the resident had returned with maggots in his wounds one time and that after that incident he would receive a shower, a head-to-toe assessment, and inspection of his wheelchair and personal items when he returned, although he had refused those assessments and inspections at times. The DON agreed the resident did not have a physician order for therapeutic leave and stated wound supplies should have been sent with him. He also stated medications were not sent with the resident and believed there was an order not to send them, but he could not provide that order. The MDS coordinator stated the resident's therapeutic leaves were not on the care plan. The facility policy for therapeutic leave stated the resident should be provided necessary medications, diet instructions, and activity restrictions using the therapeutic leave medication list.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Protect Resident from Physical Abuse and Staff Inaction
Penalty
Summary
A certified nursing assistant (CNA) responded to multiple falls of a resident with severe cognitive impairment by using physical force and restraint, without notifying a nurse or requesting assistance. The CNA lifted the resident from the floor alone, despite the resident resisting, and placed him roughly into his wheelchair. The CNA also locked the wheelchair brakes, preventing the resident from moving, and did not seek a nurse's assessment after the falls. Video footage confirmed these actions, and the resident was observed to have bruises on his arms corresponding to where the CNA had grabbed him. The resident displayed increased anxiety during interactions with the CNA. Eight additional staff members, including other CNAs, a licensed practical nurse (LPN), certified medication assistants (CMAs), and food service staff, were present during these incidents but did not intervene or report the abuse to a supervisor at the time. The LPN did not assess the resident after the falls, and staff did not assist the resident or stop the CNA from using rough handling. The resident was left on the floor for an extended period after one fall, and staff failed to follow protocols for post-fall assessment and safe transfer. Review of training records revealed that several staff members, including contracted travel staff and long-term employees, had not received required abuse and neglect training. Documentation of abuse and neglect training was missing for multiple staff, and recent staff meetings and training sessions did not include education on abuse or neglect. The facility's policy required all staff to report suspected abuse or neglect, but this was not followed during the incidents described.
Failure to Revise and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement, review, and revise fall prevention interventions for two residents with a history of falls, resulting in repeated falls and injury. One resident, who was severely cognitively impaired and had recently been evaluated by physical therapy, experienced a change in transfer status but this was not updated in the care plan. After a fall that resulted in a hip fracture, there was no evidence that new or revised interventions were implemented or documented, and the care plan was not updated to reflect changes in transfer needs or fall prevention strategies. Additionally, the resident's admission to hospice and the need for an air mattress overlay were not reflected in the care plan, and recommended interventions such as increased toileting were not added after previous falls. Another resident, also severely cognitively impaired with multiple neuropsychiatric diagnoses, experienced at least 15 falls over a two-month period, including four falls in a single day. Video footage showed that after each fall, the resident was returned to the same position without new interventions to prevent further incidents. Staff did not consistently document or implement new fall prevention measures after each event, and the care plan was not updated with additional interventions despite repeated falls. Some incident reports lacked any documented interventions, and post-fall investigation tools were often incomplete. Interviews with staff revealed a lack of training and uncertainty about where to find or how to update fall interventions in the electronic medical record. While there was an expectation from management that care plans be updated in real time after a fall, staff reported not receiving education on this process and not routinely referencing the care plan for fall interventions. The facility's policy required interdisciplinary review of falls and implementation of new interventions, but this was not consistently followed in practice.
Failure to Update and Revise Care Plans After Changes in Resident Status and Falls
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect the current care needs for two residents. For the first resident, who had severe cognitive impairment and multiple diagnoses including dementia, Alzheimer's disease, and Parkinson's disease, there were repeated falls over a two-month period. Despite multiple falls and high fall risk assessments, the care plan was not updated with new interventions after several incidents. Documentation showed that interventions were either not implemented or not recorded after many of the falls, and post-fall investigation tools were often left incomplete. The care plan was only updated after a significant delay, and did not reflect the ongoing changes in the resident's condition or the interventions that were (or should have been) put in place following each fall. For the second resident, who was also severely cognitively impaired and had a history of falls, the care plan was not updated to reflect changes in transfer status, fall prevention interventions, or hospice status. After a change in transfer method and two falls—one resulting in a hip fracture—there was no evidence that the care plan was revised to include new interventions or to address the resident's current needs. Additionally, the care plan still referenced equipment (an air mattress overlay) that was no longer in use, and did not reflect the resident's re-admission to hospice services. Interviews with staff revealed confusion and inconsistency regarding who was responsible for updating care plans and how interventions were communicated. While some staff referenced the care plan in the electronic medical record to guide care, others were unsure where to find updated interventions. The facility's policy required care plans to be revised as residents' needs changed, but this was not consistently followed, resulting in care plans that did not accurately reflect the residents' current care requirements.
Failure to Implement Action Plan and Training for Aggressive Resident
Penalty
Summary
The facility failed to implement a plan of action following an incident where a resident with cognitive impairment became physically aggressive, striking another resident in the face. The aggressive resident's behaviors were described as impulsive and unpredictable, posing a potential risk to both residents and staff. Despite the severity of the incident, there was no immediate plan or education provided to staff on how to manage such behaviors effectively. Additionally, the facility did not ensure that staff were adequately trained to handle residents with dementia and psychosocial behaviors. Interviews with staff revealed that their training on dementia and abuse was primarily conducted online, with no additional hands-on training provided. This lack of comprehensive training left staff unprepared to manage the aggressive behaviors of the resident, leading to a situation where staff and other residents were at risk. Furthermore, the facility failed to ensure that all direct caregivers were informed of updated care plan changes for residents. Staff interviews indicated a reliance on verbal communication for care plan updates, with no formal documentation or process in place to ensure all staff were aware of changes. This lack of communication and documentation contributed to the inadequate handling of the resident's aggressive behavior, as staff were not fully informed of the appropriate interventions to use.
Resident Falls Due to Unlocked Whirlpool Chair Brakes
Penalty
Summary
The provider failed to ensure the safety of a resident who fell and suffered head trauma while attempting to sit on a whirlpool chair. The incident occurred because the brakes on the whirlpool tub chair were not locked by a certified nursing assistant (CNA), leading to the chair sliding and the resident falling forward onto her face. The resident sustained supraorbital bruises, a skin tear on her right wrist, and required emergency room treatment. The resident, who had a history of falls and was at risk due to a stroke affecting her left side, was taking multiple medications that could contribute to falls. She was independent with a front-wheeled walker but required supervision for bathing. The CNA involved had recently completed orientation and had been trained on safe resident handling, including the importance of locking brakes on equipment. However, there was no signage in the tub room indicating the need to lock the tub chair wheels, and the CNA was unaware of the location of the manufacturer's instructions. The facility's policies required the use of appropriate safety measures and adherence to manufacturer's directions for equipment operation. Despite this, the communication to staff about locking brakes on shower and bath chairs was informal, with no documentation to confirm that nursing staff had read the instructions. The incident highlights a lapse in ensuring that all staff were adequately informed and reminded of safety protocols, particularly concerning the operation of bathing equipment.
Inadequate Fluid Intake Leads to Dehydration
Penalty
Summary
The facility failed to ensure adequate fluid intake for a resident, leading to dehydration. The resident, who was severely cognitively impaired and had a history of prostate cancer, urinary tract infections, and dehydration, was found on the floor multiple times, including an incident on December 8th. Following this fall, the resident exhibited confusion, lethargy, and back pain, and was later diagnosed with rib fractures, a urinary tract infection, and dehydration at a clinic visit. Observations and interviews revealed that while water was available in the resident's room, there was no consistent documentation of fluid intake outside of meals unless the resident was on a fluid restriction. The resident's fluid intake was significantly below the recommended 1,500 ml per day, with averages ranging from 480 ml to 980 ml over different weeks in December. Additionally, there was a lack of documentation for several meals, and the nursing staff did not chart fluid intake unless specifically required. The resident experienced significant weight fluctuations, with a notable weight loss from 156 pounds to 138 pounds within a week. Despite the facility's policy to reweigh residents with significant weight changes, no daily weights were completed after the documented weight loss. Interviews with staff indicated a lack of communication and follow-up regarding the resident's nutritional and hydration needs, contributing to the deficiency in care.
Failure to Complete Neurological Checks After Resident Fall
Penalty
Summary
The provider failed to ensure that neurological checks were completed for a resident after a fall, as required by their policy. The resident, who was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 3, was found on the floor beside his bed on 12/8/24. Despite the resident's history of frequent falls and his diagnoses, including Tourette's, urinary retention, weakness, urinary tract infection, dehydration, and prostate cancer, the necessary neurological checks were not documented as completed on the day shift on 12/9/24 and 12/10/24 or the night shift on 12/9/24. The facility's policy required neurological checks to be conducted every 15 minutes for four times, every hour for two times, every two hours for two times, and every four hours for two times following an unwitnessed fall. However, these checks were not performed as per the policy. The resident was later diagnosed with three rib fractures, a urinary tract infection, and dehydration after being sent to the clinic due to the inability to collect a urine sample. The resident reported falling at least once a week and sometimes every other day, indicating a pattern of falls that required careful monitoring and adherence to the facility's fall prevention and follow-up policy.
Failure to Protect Residents from Abuse and Aggression
Penalty
Summary
The provider failed to ensure the safety and well-being of a resident with a history of trauma, who expressed feelings of fear, feeling unsafe, and suicidal thoughts after an unwanted entry into her room by another resident with cognitive impairment. This resident had previously experienced an incident where the cognitively impaired resident attempted to strangle her, causing her significant distress and fear for her safety. Despite these incidents, the facility did not implement adequate interventions to prevent further unwanted encounters, leading to the resident feeling unsafe and expressing suicidal thoughts. Additionally, the provider failed to prevent acts of verbal and physical aggression between two residents. One resident, who was cognitively impaired, had multiple altercations with another resident, including incidents where they yelled, swore, and physically attacked each other. The facility's interventions were insufficient to prevent these altercations, as evidenced by repeated incidents of aggression between the two residents. The facility's policies and procedures for abuse prevention were not effectively implemented, as evidenced by the lack of adequate interventions to protect residents from aggression and unwanted encounters. The facility's failure to review psychiatric hospital notes and update care plans further contributed to the deficiency, as staff were not adequately informed of the residents' needs and behaviors that might lead to conflict or neglect.
Failure to Conduct Required Trauma Screenings
Penalty
Summary
The provider failed to ensure that trauma-informed care was provided to residents by not conducting necessary trauma screenings. One resident, who had a history of severe depression, PTSD, and anxiety, was not screened for PTSD upon admission, quarterly, annually, or after returning from an inpatient psychiatric hospitalization for suicidal ideations. This resident had been hospitalized for suicidal thoughts and had a history of PTSD related to abuse from her first husband. Despite receiving counseling from a mental health therapist, the required trauma screenings were not completed. Two other residents also did not receive the necessary trauma screenings. One resident, with severe cognitive impairment, was not screened for trauma upon admission, quarterly, or annually, and there was no documentation indicating an inability to complete the screening. Another resident, with moderate cognitive impairment, did not receive a trauma screen upon admission or on a quarterly basis, and the annual trauma screen for 2024 was not completed, although one was done in 2023. The licensed social worker responsible for conducting trauma screenings confirmed that the screenings were not completed for these residents as required. Additionally, the director of nursing did not review the hospital notes upon the return of the resident who had been hospitalized for psychiatric reasons. The facility's trauma-informed care policy mandates trauma assessments within five days of admission and as needed, but these were not adhered to, leading to the deficiencies noted in the report.
Care Plan Deficiencies in Resident Transfers and Behavioral Management
Penalty
Summary
The provider failed to ensure that care plans were reviewed and revised for four sampled residents, leading to deficiencies in care. Resident 4 experienced a fall during a transfer when a certified nursing assistant (CNA) used a stand aid lift without the required assistance of a second staff member, as per the facility's policy. Despite the resident not being injured, the care plan was outdated and did not reflect the current requirement for a full body mechanical lift due to the resident's recent surgery and weight limitations. Resident 2 exhibited wandering behavior and had a history of physical aggression towards other residents and staff. The care plan did not include interventions to prevent him from entering other residents' rooms or address his aggressive behavior. Additionally, the care plan contained outdated information, such as the names of staff members who were no longer employed, and did not reflect the interventions staff were utilizing for his wandering and behaviors. Resident 1, who had a history of PTSD and recent psychiatric hospitalization, did not have a care plan that included her suicidal ideations, PTSD, or her safety plan. The resident expressed feeling unsafe due to an incident where Resident 2 attempted to strangle her. The facility's policies on dementia care and trauma-informed care were not adequately reflected in the care plans, leading to a lack of individualized, person-centered care for the residents involved.
Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
The provider failed to ensure the safety of a resident who eloped from the facility without staff knowledge and subsequently fell, requiring evaluation at the emergency department. The incident occurred when the resident, who had a history of elopement and wore a Wander Guard device, exited the building through the front double doors. The Wander Guard was the primary intervention in place to prevent elopement, but it was not effective in this instance. Staff were supposed to monitor the resident closely, but there were no set times or frequencies for rounds or documentation of these checks. The resident, who had been diagnosed with dementia and Alzheimer's disease, was ambulatory and did not use assistive devices. On the day of the incident, the resident was found outside the building with lacerations on his nose and lips after tripping and falling. The facility's staff responded to the situation after being alerted by a passerby, but the resident had already sustained injuries by the time they reached him. The resident's care plan included the use of a Wander Guard and maintaining a calm environment, but it lacked specific boundaries for safe wandering. Interviews with staff revealed that the resident had previously eloped on multiple occasions, and the facility's interventions were limited to monitoring during normal rounding and the use of a Wander Guard. The facility's policy required an incident report and a revised care plan following an elopement, but the report does not detail any additional interventions or changes made to prevent future incidents. The deficiency highlights a lack of adequate supervision and effective interventions to prevent elopement and ensure resident safety.
Failure to Maintain Food Safety and Cleanliness in Kitchenettes
Penalty
Summary
The provider failed to adhere to necessary food safety guidelines in two kitchenettes located in the 100 and 200 hallways. Observations revealed that the exterior and interior of the refrigerators were unclean, with dried substances and unlabeled, undated food items such as vanilla frosting, bagels, sliced cheeses, salad dressings, and various sauces. The freezers contained unlabeled and undated pre-cooked pancakes and microwave bacon. Additionally, the water dispenser and ice machine were found with lime scale and slime buildup, and the kitchen surfaces and appliances, including the toaster, microwave, and stove, were unclean with dried food particles and grease. Interviews with staff, including the environmental services supervisor, director of nursing, and infection control nurse, highlighted a lack of awareness and responsibility for the cleanliness and maintenance of the kitchenettes. The dietary department, employed by the adjacent hospital, was responsible for cleaning and maintaining the kitchenettes, but failed to ensure food items were labeled and dated. The infection control nurse admitted to not auditing the kitchenettes for infection control standards, and the director of nursing was unaware of the cleaning chemicals accessible to residents. Further interviews with the cook and nutrition and food services supervisor revealed inconsistencies in cleaning practices and checklist completion. The cook admitted to cleaning the kitchen daily but only checking the fridge weekly, while the supervisor checked the kitchenettes twice a week but noted incomplete cleaning checklists. The provider's policies on equipment cleaning and leftover foods were not followed, as evidenced by the unclean kitchenettes and unlabeled food items. The lack of adherence to these policies contributed to the deficiency in maintaining a clean and safe food environment.
Failure to Report Elopement Incidents to Authorities
Penalty
Summary
The provider failed to notify the South Dakota Department of Health (SD DOH) of two elopement incidents involving a resident diagnosed with dementia and Alzheimer's disease. The resident, who had a Brief Interview of Mental Status (BIMS) score indicating an unsuccessful interview, eloped from the facility on three occasions. On the first occasion, the resident was found outside the facility after another resident alerted staff. On the second occasion, the resident was found walking outside but had not yet reached the parking lot. These incidents were not reported to the SD DOH as required. Interviews with the Director of Nursing (DON) and the Director of Nursing Trainer (DONT) revealed a lack of awareness and misinterpretation of the incidents as non-elopements. The DONT initially did not consider the incidents as elopements because they were witnessed by another resident or because the resident had not reached the parking lot. However, upon reviewing the nurse's progress notes, the DONT confirmed that these incidents should have been classified as elopements and reported accordingly. The facility's policy required incident reporting and care plan revisions following elopements, which were not adhered to in these cases.
Failure in Timely Skin Assessment and Physician Notification
Penalty
Summary
The provider failed to ensure timely skin assessments and notification to the physician for a resident identified at risk for developing skin injuries. The resident, who had a history of boils in the affected area, developed a wound on the left buttock. The wound was initially observed by a nursing supervisor and wound care nurse, who noted it was healing but had not been promptly assessed or reported to the physician when first identified. The resident's medical record indicated a care plan for impaired skin, but the interventions were not consistently followed. The CNA Skin Inspection Report showed discrepancies in documentation, with a sore identified on different dates and locations, but not consistently followed up by licensed nursing staff. The wound was not assessed by a nurse on a weekly basis as required, and there was a lack of documentation in the nurse's progress notes regarding the wound's status. Interviews with nursing staff revealed confusion and inconsistency in the skin assessment process. The wound care nurse admitted that the resident was not on a weekly assessment schedule, and the CNA's role in identifying skin concerns was misunderstood. The facility's policy on skin breakdown prevention was not effectively implemented, as deviations in skin assessment were not documented in the resident's clinical record, and a formal policy for assessing a resident's skin was not provided during the survey.
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What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chamberlain
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aurora Brule Nursing Home Inc | 31.1 mi | ★★★★★ | 10 | 0 |
| Platte Care Center | 37.2 mi | ★★★★★ | 1 | 0 |
| Avera Rosebud Country Care Center | 38.9 mi | ★★★★★ | 5 | 0 |
| Winner Regional Healthcare Center | 38.9 mi | ★★★★★ | 18 | 1 |
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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 October 2026) and official state health department websites.