Six of South Dakota’s 98 nursing homes are on a federal list of the nation’s worst-rated care facilities.
Five of the facilities are eligible for a special program to improve quality of care through increased regulatory oversight, and the other one is already in the program.
The five eligible South Dakota facilities as of the July report from the Centers for Medicare and Medicaid Services are Avantara Norton in Sioux Falls, Bennett County Hospital and Nursing Home in Martin, Dells Nursing and Rehabilitation Center in Dell Rapids, Firesteel Healthcare Center in Mitchell and Riverview Healthcare Center in Flandreau.
One facility, Good Samaritan Society Sioux Falls Center, has been participating in the Special Focus Facility program for over two years. Two other South Dakota facilities graduated from the program within the last three years: Avantara Arrowhead in Rapid City and White River Health Care Center.
The Good Samaritan facility in Sioux Falls is a 98-certified bed nonprofit nursing home. The home was found in compliance during its last state inspection report in April and met criteria for its latest federal inspection. The home has been fined by the federal government four times — for a total of $122,000 — for violations since 2020.
Nursing homes are identified as special-focus facilities based on their last three standard health survey inspections. Special-focus facilities must meet more stringent criteria two times in a row to be eligible for graduation. The Good Samaritan Center needs to meet the criteria one more time to graduate from the list.
Because the number of special-focus facilities is capped, eligible facilities – even those that have earned CMS’ lowest ratings for quality — can’t be named a special-focus facility until other homes in the same state that are already in the program are terminated from Medicare and Medicaid or improve and “graduate” from the program.
That’s a process that can take four years or more. As a result, there are several homes in each state that are deemed eligible for special-focus status due to ongoing quality-of-care issues, but can’t actually enroll in the program. It’s also why four of the five eligible South Dakota facilities have waited between 18 and 26 months on the list. Bennett County is the most recent addition, spending three months on the list so far.
Typically, the homes that are deemed eligible for special-focus designation have about twice the average number of violations cited by state inspectors; they have more serious problems than most other nursing homes, including harm or injury to residents; and they have an established pattern of serious problems that has persisted over a long period of time.
The five South Dakota homes eligible for inclusion in the Special Focus Facility program all have 1-out-of-5-star ratings from CMS. Following are summaries of the problems cited at each of those facilities, along with the one South Dakota facility already in the program.
Avantara Norton: The 110-certified bed facility in Sioux Falls is owned by for-profit company Legacy Healthcare. The home has been cited for 20 deficiencies in the last year and has been fined nearly $125,000 by the federal government since 2021.
The home was cited for cleanliness, safety hazards and staffing issues. It received a serious deficiency in its October 2022 report for failing to provide enough water to maintain a resident’s health. The resident was in “immediate jeopardy” due to staff not properly monitoring and ensuring the resident drank enough water. Because of dehydration, the resident had frequent emergency room visits due to thick urine, frequent UTIs, constipation, skin problems and poor dental health, according to the report.
Additionally, the report revealed that a staff member who’d previously been fired from the facility because of a substantiated allegation of abuse and neglect was rehired by the facility. The history was found after a resident alleged that the staff member had verbally abused them and left them sitting on a toilet seat “for a long time” until another staff member could hold them up, since the resident couldn’t walk by themselves. The staff member was fired again.
Bennett County Hospital and Nursing Home: The 27-certified bed nonprofit facility in Martin has been cited for three deficiencies in the last year and has been fined nearly $79,000 since 2021.
In its most recent recertification inspection report from April 2022, citations included infection control concerns, improperly dispensing psychotropic medications to residents and risk of safety hazards — specifically regarding residents who smoked outdoors without proper staff supervision. The facility has a nurse turnover rate of 94.4% every 12 months.
Dells Nursing and Rehab Center: The 48-certified bed facility has one deficiency reported in the last year, but it was cited for 32 deficiencies during one survey in November 2021, including an “immediate jeopardy” deficiency for residents because it did not implement proper COVID-19 precautions. The facility was fined $96,415.
Firesteel Healthcare Center: The 150-certified bed facility is owned by for-profit company EmpRes Healthcare Management. So far this year, the home has been cited for four violations. The home has been fined nearly $150,000 since 2021 — over $100,000 due to a January 2021 infection report regarding a lack of COVID-19 control that placed several residents in “immediate jeopardy” of harm.
In its most recent recertification inspection report from January, citations included improper dispensing of psychotropic medications to residents and infection control concerns.
Riverview Healthcare Center: The 49-certified bed facility in Flandreau, owned by for-profit company EmpRes Healthcare Management, has been cited for four total state and federal violations so far this year. It’s been fined $117,000 since 2021.
In its most recent recertification inspection report from February, citations included improper ulcer prevention and improper food preparation and storage.
Good Samaritan Society Sioux Falls Center: The 98-certified bed nonprofit nursing home was flagged for “immediate jeopardy” to its residents in November 2020 for a lack of infection control regarding the COVID-19 pandemic. It was placed on the special-focus facilities list in May 2021, where it was cited for 11 deficiencies in December 2021 and 10 deficiencies in June 2022. The home has been fined four times — for a total of $122,000 — for violations since 2020.
The home was found in compliance during its last state inspection report in April and met criteria for its latest federal inspection.
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