Medicine Wheel Village

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to protect the residents' right to be free from neglect for two of two sampled residents (1 and 2) by one of one certified nursing assistant (CNA) H who had not provided for the residents' activities of daily living needs. This failure resulted in resident 1 not being assisted with her toileting needs after using the call light and resident 2 developing moisture-associated skin damage to his buttock region. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.

Inspectors wroteBased on a South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interviews, and policy review, the provider failed to ensure services were delivered according to professional standards. One physician (J) gave a verbal order to the director of nursing (DON) B to borrow a controlled medication from one resident (3) and administer it to another resident (4). As a result, licensed practical nurse (LPN E) removed resident 3's controlled medication and administered it to resident 4, which is considered unacceptable clinical practice and a violation of professional standards. This citation is considered past noncompliance based on the corrective actions implemented by the provider following the incident.

Inspectors wroteA. Based on observation, interview, record review, manufacturer's instruction review, and policy review, the provider failed to ensure that staff followed standard food safety practices to sanitize dishware used to prepare and serve residents' food to prevent potential food-borne illness. That failure had the potential to affect all 28 residents who resided in the facility and placed them in immediate jeopardy for harm, illness, or death.

Inspectors wroteBased on observation, record review, and interview, the provider failed to post the required daily nursing staffing information in a location readily visible to residents, staff, and visitors that clearly reflected actual hours worked by the nursing staff for 18 of 18 days reviewed for November of 2025.

Inspectors wroteBased on interview, observation, record review, and policy review, the provider failed to ensure nine of nine sampled residents (1, 2, 4, 5, 6, 7, 14, 17, and 18) were served foods in the appropriate form according to their physician-ordered therapeutic diets.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the care plans were revised and individualized for one of one sampled resident (2) with schizophrenia, one of one sampled resident (8) who reported constant pain, and one of one sampled resident (21) who had a diagnosis of depression and anxiety and made statements of no longer wanting to live, to reflect their current needs.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure ten of ten sampled residents (1, 2, 3, 7, 8, 14, 15, 17, and 20) who used side rails on their bed had alternatives attempted prior to the implementation of those side rails and four of ten sampled residents (3, 7, 8, and 17) with side rail son their beds were assessed for safe use of those rails within the last three months according to the provider's policy.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure temperatures were maintained within a proper temperature range for safe medication storage in one of one medication room.

Inspectors wroteBased on record review, observation, interview, and policy review, the provider failed to ensure infection control practices were followed by:*Two of two certified nursing assistants (CNAs) (X and Y) who did not wear a gown while providing direct resident cares to one of one sampled resident (4) on enhanced barrier precautions (EBP) for a pressure ulcer.*One of one nursing assistant (NA) (Z) who did not change gloves and perform hand hygiene (handwashing) when she changed a resident 5's incontinence brief and assisted her into her wheelchair.*One of one licensed practical nurse (LPN) applicant (P) who did not perform hand hygiene during an insulin administration to resident 23.*One of one registered nurse (RN)/Minimum Data Set (MDS)/skin and wound nurse (L) who did not perform hand hygiene when she changed resident 14's dressing.

Inspectors wroteBased on the resident council meeting, resident council meeting minutes review, grievance logs review, observation, interview, record review, and policy review, the provider failed to respond to the resident concerns communicated at resident council meetings regarding nursing care being performed in public and loud televisions.

Inspectors wroteBased on resident council minutes review, interview, and policy review, the provider failed to ensure one of one certified nursing assistant (CNA)/activity staff (Q) who documented allegations of neglect regarding residents' personal care reported by residents, during an 11/12/25 resident council meeting reported those allegation to the administrator according to the provider's policy which resulted in those allegations not being reported to the South Dakota Department of Health (SD DOH) in the required time frame of no more than 24 hours after the allegations were made.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure one of one sampled resident (2) diagnosed with schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves, causing a distorted sense of reality) had an accurate level I (1) Preadmission Screening and Resident Review (PASRR) evaluation after having been identified as having a possible serious mental illness.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow professional standards to ensure the effectiveness and adverse reactions of an antidepressant medication were documented for one of one sampled resident (21) with a newly ordered antidepressant medication (fluoxetine) for anxiety and depression.

Inspectors wroteBased on interview and record review, the provider failed to ensure one of one dietary manager (DM) (F) was certified according to the requirements.

Inspectors wroteBased on interview and policy review, the provider failed to ensure Medical Director (BB) attended and meaningfully participated in the provider's Quality Assurance (QA) meetings at least quarterly.

Inspectors wroteBased on policy review, interview, and record review, the provider failed to develop and implement an effective antibiotic stewardship program to monitor for appropriate antibiotic use according to the provider's policy.

Inspectors wrote2. Observation on 9/30/24 at 3:45 p.m. of unidentified CNA during the initial tour in the kitchen revealed: *CNA was making ham salad sandwiches for the residents' evening meal. *CNA was not using a measuring scoop to correctly portion the amount of salad put on each sandwich. *The bread used for the sandwich was a slider bun, approximately one-half the side of a standard hamburger bun. Observation on 10/2/24 at 4:13 p.m. of cook J revealed: *While preparing the cucumbers with ranch portions, she was not using a measuring utensil to measure the portion for each meal tray. *While preparing the three bean salad portions, she was not using a measuring utensil to measure the portion for each meal tray. Interview on 10/1/24 at 8:35 a.m. with dietary manager E revealed: *The CNA that was making the ham salad sandwiches was not part of the regular kitchen staff. [...]

Inspectors wroteBased on Certification and Survey Provider Enhanced Reports (CASPER) reporting data review, interview, and policy review, the provider failed to ensure their Payroll Based Journal (PBJ), (information of the provider's daily staffing hours for the appropriate care of the residents) had been complete and the data had been submitted to the Center for Medicare and Medicaid Services (CMS) for one of four quarters (Quarter 1, 2024).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incidents (FRI) review, interview, and policy review, the provider failed to provide timely and thorough notification to SD DOH for two of two sample residents (2 and 6) who required evaluation at the emergency room, after sustaining an injury during a transfer (2), and after an unwitnessed fall (6).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to provide the therapeutic diet prescribed by a physician for 16 of 21 (2,3,4,5,7,8,9,11,12,13,14,16,17,18,19,21) residents.

Inspectors wroteBased on observation, interview, record review and policy review the provider failed to ensure two of two sampled residents (2 and 18) with open wounds had been placed on enhanced barrier precautions (EBP).

Inspectors wroteBased on interview, record review, and document review, the provider failed to provide a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman for one of one sampled resident (13) reviewed for facility-initiated transfer to the hospital.

Inspectors wroteBased on record review, interview, and policy review the provider failed to ensure one of one sampled resident (1) had her as needed (PRN) lorazepam (antianxiety medication) order renewed for continued use beyond 14 days.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure that one of one sampled resident (1) received a food prepared to correct temperature.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure nursing staff followed physician orders for oxygen use and nebulizer tubing changes for six of six sampled residents (16, 2, 30, 23, 8, and 9) who received oxygen and nebulizer therapy.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure: *Two of three dietary staff (F and S) had performed proper hand hygiene and glove use during one of one meal service observation. *Potentially hazardous food was stored according to the manufacturer's guidelines.

Inspectors wroteBased on observation, interview, record review, and diet manual review, the provider failed to: *Preserve the nutritive value of pureed foods for two of two sampled residents (5 and 8) by thinning the food items with plain water. *Provide a pureed substitute for a menu item of similar nutritive value for two of two sampled residents (5 and 8) who required a pureed diet for one of one observed meal service.