Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Wakonda Heritage Manor during CMS and state inspections, most recent first.
Failure to Document Restraint Assessment and Alternatives: A resident with severe cognitive impairment was observed in a manual recliner with her feet elevated and a Tabs monitor attached, while records showed a restraint consent, physician order, care plan interventions, and a restraint assessment related to falls, self-transfer attempts, and alarm use. Staff interviews confirmed the resident could not release the recliner herself and that her feet were not supposed to be elevated, and the DON and MDS RN acknowledged the resident was restrained during observation, but the restraint assessment lacked documentation supporting why the recliner use was not considered a restraint.
MDS Assessment Not Accurately Coded for Active PTSD Diagnosis: A resident’s quarterly MDS failed to mark PTSD as an active psychiatric diagnosis in Section I even though the diagnosis had been added to the EMR before the assessment. The MDS RN acknowledged the diagnosis was active at the time of completion and stated she used UDA's, physician orders, diagnoses, progress notes, and staff interviews, along with the CMS RAI manual, when completing MDS assessments.
Nebulizer equipment was not cleaned after use for a resident receiving Budesonide and Formoterol via nebulizer for COPD. Staff observations showed clear liquid remained in the medication chamber across multiple checks, and the resident was unsure whether an RN had rinsed the tubing after use. An LPN stated she administered the treatments but did not clean the nebulizer attachments that day, despite the DON’s expectation and the facility policy requiring the nebulizer mask or pipe to be cleaned after each use and allowed to air-dry before reuse.
Unlocked bathing room and cabinet doors allowed residents access to stored chemicals and bathing products. Surveyors observed a bathing room unattended with the door unlocked and the storage cabinet unlocked on two occasions, with disinfectant cleaner and multiple personal care items inside. A CNA said the door should have been locked after an independent resident showered, and the DON stated bathing rooms were expected to be locked when not in use. The facility also had 21 residents listed with Alzheimer's/Dementia, and its chemical storage policy required chemicals to be kept inaccessible to residents and visitors when not in use.
Two residents assessed as unable to safely use electronic lift chairs independently had access to the controls, leading to a deficiency. One resident, with a history of falls and severe cognitive impairment, fell from the chair, which was found plugged in with the control accessible. Another resident, also severely cognitively impaired, was observed using the lift chair independently despite care plan directives. The facility failed to consistently implement its policy to unplug lift chairs for residents assessed as unsafe.
During a meal service, dietary staff failed to follow proper hand hygiene and glove use protocols. The dietary manager handled various surfaces and ready-to-eat foods without changing gloves, while a medical secretary reused trays and did not wash hands between meal deliveries. Both staff members did not adhere to the facility's hand hygiene policies.
A resident on an NDD2 diet experienced a choking incident after being served steak during a special Father's Day meal, which was not reviewed by a registered dietitian as required. The resident was hospitalized for removal of steak pieces and returned with a modified diet order. The dietary manager admitted the meal was not documented for dietitian review, contrary to facility policy.
Failure to Document Restraint Assessment and Less Restrictive Alternatives
Penalty
Summary
The provider failed to ensure there was documentation to support whether one resident was a candidate for restraint reduction, a less restrictive method, or restraint elimination. Resident 6 was observed sitting in a manual recliner in the lounge area with her feet elevated and a Tabs monitor attached to her clothing, and later was observed sleeping in the same recliner with the Tabs monitor still attached. The resident had severe cognitive impairment, with a BIMS score of 2, and had a physical restraint consent dated 3/8/26 for a Tabs alarm/pressure mat signed by a family member. Record review showed the resident had a physician order to ensure the Tabs alarm was on during day and night shifts due to dementia. Her care plan included a focus on needing help with all ADLs, frequent bladder incontinence, and being unsteady at times, with an intervention that she may use a recliner without feet up. A lift chair safety assessment stated she was not safe to use a lift chair on her own and had a manual recliner in her room. A restraint assessment dated 3/9/26 documented continued imminent danger to the resident or others, with unsteady gait, agitated behaviors, forgetting her ambulation device, frequent falls, attempted self-transfer, and climbing out of bed; the alternatives attempted were alarm devices on the bed and chair. Additional notes documented falls in the lounge area and a behavior note stating the resident had been attempting to stand from her recliner, leaning forward in the recliner, and trying to remove her Tabs alarm. During interviews, staff stated the resident could self-transfer at times, could not release the recliner herself, and was not supposed to have her feet in the upright position when sitting in the lounge recliner. The MDS Coordinator/RN and DON acknowledged that the resident was restrained during surveyor observations, and the MDS/RN stated there was no documentation on the physical restraint assessment form to support why the recliner position was not considered a restraint.
MDS Assessment Not Accurately Coded for Active PTSD Diagnosis
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one sampled resident when the 3/24/26 quarterly MDS did not correctly code an active diagnosis of post-traumatic stress disorder (PTSD) in Section I under Psychiatric/Mood Disorder. The resident’s EMR showed she was admitted to the facility on [DATE], and PTSD was added to her diagnoses on 1/5/26, but the diagnosis was not marked on the assessment as an active diagnosis. During interview and EMR review on 5/7/26 at 8:42 a.m., the MDS Coordinator/RN acknowledged the resident had a PTSD diagnosis when the quarterly MDS was completed and agreed that Section I should have been marked for PTSD. The RN stated she used UDA's completed by the nurse, physician’s orders, resident diagnoses, progress notes, and staff interviews when completing MDS assessments, and referenced the CMS LTC Facility RAI 3.0 User’s Manual Version 1.20.1 October 2025. The manual excerpt reviewed stated that physician diagnoses should be identified using available medical record sources such as the most recent history and physical, transfer documents, discharge summaries, and progress notes.
Nebulizer equipment was not cleaned after use
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was deficient when staff did not follow infection control practices for resident 34’s nebulizer equipment. On 5/5/26, observations in the resident’s room showed a handheld nebulizer tube connected to a nebulizer machine with clear liquid remaining in the medication chamber at 9:38 a.m. and again at 1:22 p.m. Later that day, the resident stated she was unsure whether RN C had rinsed out her nebulizer tube after she used it that morning. On 5/6/26, the nebulizer tube was observed with a small amount of clear liquid in the medication chamber at 8:10 a.m. and remained in the same position with clear solution still present at 4:00 p.m. Record review showed resident 34 had physician’s orders for Budesonide suspension 0.5 mg/2 mL via nebulizer twice daily and Formoterol nebulizer 20 mcg/2 mL twice daily for COPD. An LPN stated she administered the nebulizer treatments that morning and that the resident received Budesonide and Formoterol separately; she said she would take apart the medication chamber and pieces, rinse them out, and place them on a barrier to air dry after the resident finished, but she did not clean the nebulizer attachments that day. The DON stated staff were expected to follow the policy for rinsing out the nebulizer medication chamber and pieces after each administration and to verify the medication was administered. The facility policy stated nebulizer mask or pipe must be cleaned after each use, disinfected according to manufacturer guidelines and facility infection control procedures, and allowed to air-dry completely before reuse.
Unlocked bathing room allowed access to stored chemicals
Penalty
Summary
The nursing home failed to ensure chemicals were stored safely away from residents in one of two bathing rooms. On 5/5/26 at 2:51 p.m., surveyors observed the bathing room unattended with the door unlocked, and the storage cabinet that contained skin care products and chemicals was also unlocked. The cabinet held a spray bottle of Ecolab rapid Multi Surface Disinfectant Cleaner, an aerosol can of Arrid extra dry antiperspirant, a can of UltraSure deodorant body spray, lotions, shampoos, skin creams, deodorants, and a skin protection ointment, and a bottle of Gentell baby shampoo was on top of the cabinet. On 5/6/26 at 11:03 a.m., the bathing room door and the storage cabinet door were again observed unlocked, allowing residents access to the items inside the cabinet, and several residents passed the room on their way to the dining room for lunch. A CNA stated the door should have been locked and that it likely was not relocked after an independent resident showered the day before. The administrator stated she knew cleaning chemicals and resident bathing products were stored in the bathing rooms and expected the rooms to be locked when not in use. The facility’s CMS 802 matrix showed 21 residents were marked as having Alzheimer's/Dementia, and the revised November 2025 Chemical Product Labeling and Storage policy stated that all chemicals must be kept inaccessible to residents and visitors when not in use.
Failure to Prevent Unsafe Use of Lift Chairs
Penalty
Summary
The deficiency involves the failure of the facility to ensure that two residents, who were assessed as unable to safely use electronic lift chairs independently, did not have access to the lift chair controls or that the chairs' power cords were unplugged or removed as directed in their assessments. Resident 3, who had a history of falls and was severely cognitively impaired, was found on the floor after falling from his lift chair, which was in the most upright position. Despite assessments indicating he was unsafe to operate the lift chair independently, the chair was found plugged in with the control accessible in the side pocket. Resident 3's medical history included depression, paranoid schizophrenia, epilepsy, insomnia, aphasia, and cerebral infarction, with noted balance problems and a history of falls. His care plan was updated to reflect his inability to safely operate the lift chair, yet observations during the survey revealed the chair remained plugged in, contrary to the care plan directives. Interviews with staff indicated a lack of consistent adherence to the care plan, as the chair was sometimes unplugged but not consistently. Similarly, Resident 21, who was also assessed as unsafe to use the lift chair independently due to severe cognitive impairment, was observed using the lift chair with the control accessible. Her care plan indicated she required assistance with the lift chair, yet the chair was not unplugged, and she was able to operate it independently. The facility's policy required that lift chairs for residents assessed as unsafe be unplugged, but this was not consistently implemented, leading to the deficiency.
Improper Hand Hygiene and Glove Use During Meal Service
Penalty
Summary
The deficiency involved improper hand hygiene and glove use by dietary staff during a meal service in the kitchen and dining room. Dietary manager J, while wearing gloves, touched various surfaces including trays, diet cards, her cap, plates, and serving utensils, and then handled ready-to-eat dinner rolls without changing gloves. Medical secretary K reused trays to deliver meals, touched residents, and did not wash her hands during the meal service. Both staff members failed to adhere to proper hand hygiene practices as outlined in the facility's policies. Interviews revealed that dietary manager J, who was responsible for training dietary staff, was unaware of the need to change gloves when handling ready-to-eat foods and did not instruct medical secretary K to wash her hands between meal deliveries. The director of nursing, acting as the infection preventionist, expected adherence to hand hygiene policies but was unaware of the dietary manager's misconceptions about glove use. The facility's policies and training materials clearly stated the importance of handwashing before and between glove changes, and the need to avoid contaminating gloves by touching non-disinfected surfaces.
Failure to Review Menu Substitutions Leads to Choking Incident
Penalty
Summary
The provider failed to ensure that menu substitutions for a special Father's Day meal were reviewed and approved by a registered dietitian, leading to a choking incident involving a resident. The resident, who was on an NDD2 diet with regular meat, experienced choking after being served steak, which was not part of the original menu and had not been documented in the menu substitution log for dietitian review. The resident was subsequently hospitalized for the removal of steak pieces from his throat and returned with a modified diet order. The dietary manager acknowledged that the special meal was not added to the substitution log, which was against the facility's policy. The director of nursing confirmed that the resident's diet was changed following a speech evaluation after the incident. The administrator admitted uncertainty about whether special meal menus were documented for dietitian review, agreeing that the policy should have been followed. The facility's policy required all menu changes to be recorded and reviewed by a registered dietitian, which was not adhered to in this case.
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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 Wakonda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunset Manor Avera Health | 6 mi | ★★★★★ | 12 | 0 |
| Centerville Care And Rehab Center Inc | 10.8 mi | ★★★★★ | 0 | 0 |
| Pioneer Memorial Nursing Home | 11.7 mi | ★★★★★ | 0 | 0 |
| Sd Human Services Center - Geriatric Program | 16.2 mi | ★★★★★ | 0 | 0 |
| Bethesda Of Beresford | 17 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.