Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dow Rummel Village during CMS and state inspections, most recent first.
A CMA administered medications intended for one resident to another, resulting in the recipient experiencing nausea, vomiting, and anxiety, and requiring evaluation at the emergency department. The error was recognized and reported by the CMA, but other staff administering medications were not formally educated or re-educated about the incident or medication administration policy, and there was no evidence of facility-wide education or monitoring following the event.
A resident with severe cognitive impairment and multiple comorbidities was transferred by a CMA and CNA using a stand and pivot method instead of the care-planned sit-to-stand mechanical lift with two staff. The staff made this decision due to the resident's anxiety, without consulting nursing leadership. During the transfer, the resident sustained a large laceration to the right lower leg, requiring emergency department treatment and sutures.
A resident with a shellfish allergy was served shrimp Alfredo, leading to an allergic reaction. The dietary staff missed the allergy information on the tray ticket, and there was inadequate communication between nursing and dietary staff. The facility's policy on offering food replacements was not effectively implemented, particularly for residents on puree diets.
The facility failed to document food allergies in the care plans of four residents, leading to an incident where a resident with a shellfish allergy was served shrimp and had an allergic reaction. Interviews revealed that CNAs relied on pocket care plans, which did not list allergies, and were unaware of where to find allergy information. Nursing and dietary staff confirmed that allergies were not consistently included in care plans, despite being discussed during assessments and conferences.
The facility failed to submit their Payroll Based Journal (PBJ) data to CMS on time for the first quarter of 2024. The data, covering January to March 2024, was submitted late on May 15, missing the deadline. Interviews with the executive directors confirmed the late submission, and the executive director of human resources was responsible for ensuring timely PBJ submissions.
Significant Medication Error Due to Incorrect Resident Identification
Penalty
Summary
A certified medication aide (CMA) administered a set of medications intended for one resident to a different resident, resulting in a significant medication error. The error occurred when the CMA prepared medications for a resident who typically ate breakfast in her room but, on this occasion, was found in the dining room. The CMA mistakenly identified another resident as the intended recipient and administered the wrong medications. The error was recognized by the CMA upon reviewing the medication label and was immediately reported to the charge nurse on duty. The resident who received the incorrect medications had a medical history including a left pelvic fracture, paroxysmal atrial fibrillation, type 2 diabetes mellitus with chronic kidney disease, and carotid artery stenosis. After receiving the wrong medications, the resident initially denied symptoms but later experienced nausea, vomiting, and lightheadedness, leading to a request for evaluation at the local emergency department. The incident was documented, and the resident was monitored as per provider instructions. Interviews and record reviews revealed that other staff members who administered medications were not formally educated or re-educated about the incident or the medication administration policy following the error. Several staff members were unaware of the specifics of the incident or could not recall the six rights of medication administration. There was no evidence of formal staff-wide education, monitoring, or auditing of medication administration practices after the event, and the facility's policies did not specify requirements for staff education or follow-up monitoring after such incidents.
Failure to Follow Individualized Transfer Care Plan Results in Resident Injury
Penalty
Summary
Certified medical assistant (CMA) G and certified nursing assistant (CNA) I failed to follow the individualized care plan for a resident who required assistance with transfers using a sit-to-stand mechanical lift and two staff members. Instead, they performed a stand and pivot transfer, deviating from the prescribed method. This decision was made because the resident was reportedly anxious, and the staff believed using the mechanical lift would increase her agitation. The staff did not consult with nursing leadership or the resident's care team before making this change. During the unauthorized transfer, the resident's right leg was positioned next to the CNA's left leg. After the transfer, blood was discovered on the resident's pant leg and the CNA's shoe. Upon assessment by nursing staff, a large laceration was found on the resident's right lower leg, which required emergency medical attention and sutures. The resident was transferred to the emergency department for treatment and later returned to the facility with wound care instructions. The resident involved had a severely impaired cognitive status, as indicated by a Brief Mental Status (BIMS) score of 0, and multiple diagnoses including Alzheimer's disease, dementia, anxiety, iron deficiency anemia, localized edema, chronic peripheral vascular disease, and hypertension. The facility's policy required staff to follow the resident's care plan for safe transfers and to consult nursing leadership if uncertain about transfer methods. Despite this, the staff independently decided to alter the transfer method without proper consultation or documentation.
Failure to Prevent Allergic Reaction Due to Dietary Oversight
Penalty
Summary
The facility failed to ensure that a resident with a documented shellfish allergy was not served shrimp Alfredo, leading to an allergic reaction. On the day of the incident, the dietary staff did not identify the resident's allergy on the tray ticket, resulting in the resident being served pureed shrimp Alfredo. The resident subsequently developed a rash around the mouth and redness in the mouth and throat, necessitating the administration of Benadryl. Interviews with dietary staff revealed that the cook responsible for serving the meal admitted to missing the allergy information on the tray ticket. The cook suggested that allergies should be highlighted on tray tickets to increase awareness among dietary staff. Additionally, there was a lack of communication between nursing and dietary staff regarding the presence of shellfish on the menu and the residents with known allergies. The facility's policy on offering food replacements was not effectively implemented, particularly for residents on puree diets. The dietary staff did not offer alternative food options to residents on puree diets, as the menu did not include puree options. This oversight may have contributed to the failure to check the resident's tray ticket closely, resulting in the resident being served a meal containing an allergen.
Failure to Document Food Allergies in Care Plans
Penalty
Summary
The provider failed to develop comprehensive care plans that included interventions for documented food allergies and intolerances for four sampled residents. This deficiency was highlighted when a resident with a known shellfish allergy was served shrimp and subsequently developed an allergic reaction. Interviews with CNAs revealed that they relied on pocket care plans to understand resident needs, but these plans did not list the residents' food allergies. Additionally, CNAs were unaware of where to find information on food allergies or intolerances, indicating a lack of communication and documentation. Further interviews with nursing staff and dietary management confirmed that food allergies were not consistently included in the residents' care plans. The Director of Culinary Services acknowledged the importance of listing food allergies in care plans, but noted that food preferences and intolerances were only discussed during admission assessments and quarterly care conferences. Record reviews showed that the documented allergies for the four residents were not included in their care plans or pocket care plans, contrary to the facility's care plan policy, which mandates comprehensive care plans to address residents' needs.
Late Submission of PBJ Data to CMS
Penalty
Summary
The provider failed to ensure the timely submission of their Payroll Based Journal (PBJ) data to the Center for Medicare and Medicaid Services (CMS) for the first quarter of 2024. The Certification and Survey Provider Enhanced Reports (CASPER) data review revealed that no PBJ data had been submitted for the period from January 1, 2024, through March 31, 2024. During an interview with the executive director, the executive director of support services, and the executive director of human resources, it was confirmed that the PBJ data was submitted late on May 15, 2024, at 11:23 p.m. central time, missing the deadline of 11:59 p.m. eastern time. The job description for the executive director of human resources included responsibilities for overseeing the payroll department and ensuring the accurate and timely submission of the PBJ Quarterly Report to CMS.
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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 Sioux Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society Sioux Falls Center | 0.8 mi | — | 4 | 0 |
| Bethany Home Sioux Falls | 2.2 mi | — | 3 | 0 |
| Good Samaritan Society Luther Manor | 2.9 mi | — | 11 | 0 |
| Avantara Norton | 3.3 mi | — | 21 | 0 |
| Good Samaritan Society Sioux Falls Village | 4.1 mi | — | 0 | 0 |
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