Home / South Dakota / Hot Springs
Michael J Fitzmaurice South Dakota Veterans Home
2500 Minnekahta Avenue, Hot Springs, SD 57747 · Fall River County · (605) 745-5127
78 certified beds, about 52 residents a day · Government - State · Medicaid since 2011
Certified for Medicaid
Overall
4 of 5
Health inspections
4 of 5
Staffing
Not rated
CMS note: Not enough data available to calculate a star rating.
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 43A136 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on July 9, 2026, inspectors cited 1 health deficiency (the South Dakota average is 6.7, the national average 9.2).
Of 13 health citations since February 2024, 2 were rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $39,293 in the last three years; the largest was $39,293, and the latest is dated May 1, 2025.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
602/24
605/25
107/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
6D
4E
1F
Potential for minimal harm
0A
0B
0C
July 9, 2026Standard inspection · 1 citation
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interview, the provider failed to ensure that the resident's baseline care plan (a standardized, person-centered guide developed for newly admitted residents) was completed, reviewed with the resident or the resident's representative, and that a written copy was provided to the resident or their representative within 48 hours of the resident's admission to the facility for two of two sampled residents (8 and 48).
May 1, 2025Standard inspection, Complaint inspection · 6 citations
- G Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, record review, and interview, the provider failed to protect the resident's right to be free from neglect by one of one licensed practical nurse (LPN) (U) who failed to initiate standing orders for an upset stomach for one of one sampled resident (210) after he became sick in the dining room at supper time and later that night aspirated on his emesis and passed away. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented immediately following the incident.
- G Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure ordered treatments for a current pressure ulcer (skin wound caused by prolonged pressure) were completed and preventative interventions were consistently implemented for one of one sampled resident (47) who developed additional pressure ulcers (wounds) on his toes.
- F Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation, interview, and policy review, the provider failed to ensure proper infection control practices were followed regarding: *Hand hygiene and personal protective equipment (PPE) use by four of four observed staff (E, O, R, and S) for one sampled resident (360) with a physician order for contact precautions related to an infected unhealed chest wound and two sampled residents (10 and 49) on enhanced barrier precautions (EBP) who resided in the NASA unit. *The storage and maintenance of wound care supplies in one of one observed treatment cart located in the NASA unit.
- E Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure an environment free from potential hazards by not following their policy and ensuring that lighters for two of two sampled residents (33 and 42) who smoked were secured at the nurses' station when not in use.
- E Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to assess bed rails for safe use for five of five sampled residents (24, 28, 41, 44, and 47) who had bed rails on their beds.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure the care plan was reviewed and revised to reflect the current necessary care needs for one of one sampled resident (47).
February 15, 2024Standard inspection · 6 citations
- E Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to: *Ensure the paper copy of the standardized protocol for stage II pressure ulcer interventions was followed according to policy for one of two sampled residents (27) with a stage II facility acquired pressure ulcer (a skin injury incurred while residing at the facility). *Implement the use of a pressure-reducing device to mitigate the risk for one of two sampled residents (27) who developed a stage II facility acquired pressure ulcer.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for the following: *Effective whirlpool (WP) tub cleaning by one of one certified homemaker (J) in one of five multi-use resident WP tub rooms after bathing one of one sampled resident (8). *Appropriate mask, face shield, and gown use by one of one licensed practical nurse (LPN) (I) during care for one of four sampled residents (34) on transmission-based precautions (TBP). *Appropriate face shield and mask use by one of one certified homemaker (L) during care for one of four residents (52) on TBP. *Appropriate hand hygiene, glove use, and dressing application by one of one LPN (I) during a dressing change for one of two sampled residents (27).
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *The psychosocial well-being and dignity was maintained for one of four sampled residents (46) during three of three observed meal services. *Privacy for one of two sampled residents (29) was provided during his Foley catheter care.
- D Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to identify one of four sampled residents (46) seated in a wheelchair was restrained with locked brakes pushed against a countertop.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *One of one four residents (46) at risk for skin breakdown was repositioned according to the protocol of the facility. *One of four sampled residents (46) received proper and timely peri-care following a bowel movement.
- D Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of two sampled residents (57) with a physician ordered renal dialysis diet was implemented.
Fire safety inspections
1 fire safety citation on file: 1 on May 1, 2025.
Every fire safety citation1 citation
- C Develop and maintain an Emergency Preparedness Program (EP).
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| May 1, 2025 | Fine | $39,293 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | South Dakota | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | not reported | 3.79 | 3.86 |
| Registered nurses | not reported | 0.80 | 0.69 |
| All nursing staff on weekends | not reported | 3.26 | 3.42 |
| Nurse aides | not reported | ||
| Licensed practical nurses | not reported | ||
| Nursing staff turnover (share who left in a year) | not reported | 48.2% | 45.8% |
| Registered nurse turnover | not reported | 34.7% | 42.9% |
| Administrators who left | not reported |
CMS note on this home's staffing data: This facility submitted data that did not meet the criteria required to calculate a staffing measure.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In October to December 2025, nursing staff hours per resident were 7.55 on weekdays and 5.84 on weekends, 23% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 19.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 6.62 in April to June 2025 to 7.07 in October to December 2025.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Oct to Dec 2025 | 7.07 | 1.35 | 7.55 | 5.84 | 19.2% | 0 of 92 | 57 |
| Jul to Sep 2025 | 6.65 | 1.11 | 7.14 | 5.39 | 27.6% | 1 of 92 | 59 |
| Apr to Jun 2025 | 6.62 | 1.14 | 7.09 | 5.45 | 29.5% | 0 of 91 | 58 |
| United States, Oct to Dec 2025 | 3.76 | 0.62 | 3.93 | 3.34 | 5.3% | 0.5% of days | |
| South Dakota, Oct to Dec 2025 | 3.80 | 0.81 | 4.01 | 3.26 | 9.7% | 1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | South Dakota | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 20.7 | 21.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 2.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 5.7 | 2.9 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 8.4 | 5.5 | 3.2 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 13.4 | 19.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.9 | 4.6 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 33.7 | 24.6 | 15.4 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.5 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.7 | 1.8 | 1.8 |
Owners and operators
Legal business name: Legal Business Name Not Available.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 4 problems in this area, most recently on May 1, 2025: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
- When is the care plan meeting, and can family attend it?Inspectors cited 2 problems in this area, most recently on July 9, 2026: "Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted"
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 2 problems in this area, most recently on May 1, 2025: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 2 problems in this area, most recently on May 1, 2025: "Provide and implement an infection prevention and control program."
Other nursing homes nearby
- Seven Sisters Living Center Hot Springs, 1.4 mi · 4 of 5 stars · 10 citations
- Custer Care and Rehab Center Custer, 23.6 mi · 1 of 5 stars · 19 citations
South Dakota contacts for a concern about a nursing home
These are the official offices in South Dakota. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: South Dakota Department of Health, Office of Health Facilities Licensure and Certification, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: South Dakota Long-Term Care Ombudsman Program, Department of Human Services. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: South Dakota Department of Health Nursing Facility Reports, where South Dakota publishes its own records on licensed homes.
Common questions
- What is Michael J Fitzmaurice South Dakota Veterans Home's Medicare star rating?
- CMS rates Michael J Fitzmaurice South Dakota Veterans Home 4 out of 5 stars overall, with 4 for health inspections, no for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Michael J Fitzmaurice South Dakota Veterans Home get at its last inspection?
- 1 health deficiency at the standard inspection on July 9, 2026. The South Dakota average is 6.7.
- Has Michael J Fitzmaurice South Dakota Veterans Home been fined?
- Yes. CMS lists 1 fine totaling $39,293 in the last three years.
- Does Michael J Fitzmaurice South Dakota Veterans Home accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Michael J Fitzmaurice South Dakota Veterans Home?
- CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.