Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 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 Medicine Wheel Village during CMS and state inspections, most recent first.
A CNA failed to respond appropriately to call lights and did not provide required ADL, toileting, and incontinence care to two dependent residents during a night shift. One resident, with multiple comorbidities and moderate cognitive impairment, was left without toileting assistance after using the call light, and only received help when an LPN and RN intervened. Another resident, with obesity, TBI, contracture, and documented need for two-person assist and scheduled toileting, was not checked or toileted as care-planned. Both residents were later found with heavily saturated incontinence products and urine-soaked beds, and one developed moisture-associated skin damage to the buttocks.
Staff failed to follow professional standards when a physician verbally instructed the DON to have nurses borrow a controlled medication (Lorazepam 0.5 mg) from one resident and administer it to another resident experiencing anxiety after other comfort measures failed. Because the ordered medication was not available on site, the pharmacy was closed, and the family declined ER transfer, an LPN removed a Lorazepam tablet from the first resident’s medication card and gave it to the second resident. This action bypassed facility policies requiring proper ordering, accountability, and use of controlled drugs only for the resident for whom they were prescribed, and the administrator, DON, and consultant pharmacist later acknowledged that borrowing medications between residents is not acceptable practice.
A CNA/activity staff member failed to report residents' allegations of neglect, documented during a resident council meeting, to the administrator as required by policy. This resulted in a delay of several days before the administrator and the SD DOH were notified, violating the required 24-hour reporting timeframe for such allegations.
The facility failed to provide a well-balanced diet that considered residents' preferences and dietary needs. Residents were not given meal choices, and if they refused the meal, they were only offered soup. Food portions were inconsistent due to short staffing, and the registered dietician was not informed of menu substitutions. The facility's policy to provide meals according to residents' needs and preferences was not consistently followed.
The facility failed to submit Payroll Based Journal (PBJ) data for Quarter 1, 2024, to CMS on time. The administrator and outsourced CFO were aware of the submission requirements, but a staff member from the CFO's office missed the deadline by one day. The facility's policy mandates timely submission of staffing information, which was not followed for this quarter.
The facility failed to timely report incidents involving two residents to the SD DOH. One resident experienced a knee injury during a transfer, which was not immediately documented or reported, leading to a delayed diagnosis of a tibial fracture. Another resident had an unwitnessed fall, and despite her complaints of pain, the incident was not promptly documented or reported. The DON admitted to falling behind in reporting duties, resulting in incomplete and delayed notifications to the SD DOH.
The facility failed to provide therapeutic diets as prescribed by physicians for 16 residents. Meals served did not align with approved menus, and there was no documentation or approval from the dietician for substitutions. All residents received the same meal without differentiation between their prescribed diets. The dietary manager admitted to making substitutions without notifying the dietician, and the administrator acknowledged challenges in adhering to prescribed diets due to resident preferences.
The facility failed to implement enhanced barrier precautions (EBP) for two residents with open wounds. Staff did not wear gowns or gloves during transfers or wound care, despite the presence of EBP signage and supplies. Interviews revealed a lack of understanding of the EBP policy, with staff believing it was only necessary for residents with multi-drug resistant organisms (MDROs). The facility's policy required EBP for all residents with wounds, highlighting a discrepancy in practice.
A facility failed to notify the State Long-Term Care Ombudsman of a resident's hospital transfers, as required by regulations. The resident was transferred twice, with the POA informed but no documentation of bed hold information provided. Social services staff were unaware of the need to report each transfer, and the Ombudsman confirmed not receiving notifications.
A resident's PRN lorazepam order was not renewed beyond the 14-day limit, despite being administered 21 times over a period. The facility's policy requires PRN orders for psychotropic medications to be renewed every 14 days, but the order was not updated until after the medication had been used extensively. Interviews with the DON and an LPN revealed they were unaware of the lapse in renewal, leading to a deficiency in medication management.
A resident received food that was not prepared to the correct temperature due to a malfunctioning warming cabinet thermometer. The dietary staff did not recheck or reheat pureed meals to ensure they were above 135°F before serving. The facility's policy on food temperatures was not followed, and the maintenance department was aware of the issue for months without resolution.
Neglect of ADL and Toileting Care by CNA Resulting in Incontinence-Related Harm
Penalty
Summary
The deficiency involves a CNA’s failure to provide required ADL care and toileting assistance to two dependent residents during a night shift, resulting in neglect. On the night in question, an LPN observed that the traveling CNA repeatedly refused to answer residents’ call lights, spent time on her cell phone, and did not toilet residents or change their incontinence products. When one resident activated her call light, the CNA entered the room, turned off the call light, and left without assisting the resident. Shortly afterward, the call light was activated again, and the LPN responded, finding that the resident needed to use the bathroom and reported that the CNA would not help her. The LPN, with an RN, then assisted the resident to the toilet, provided hygiene care, and returned her to bed. The first resident involved had multiple medical conditions, including arthritis, a history of hip fracture, a chronic non‑pressure ulcer of the right lower leg, a bone density disorder, and mild dementia, with a BIMS score indicating moderately impaired cognition. Her care plan required total assistance with ADLs, dependence on staff for all transfers using a Hoyer lift, staff assistance with toileting or bedpan use, hygiene assistance as needed, and turning and repositioning every one to two hours while in bed. Despite these documented needs, the CNA did not provide the required toileting and hygiene assistance when the resident requested help via the call light, and the resident’s needs were only met when the LPN and RN intervened. The second resident involved also had significant medical and functional limitations, including obesity, arthritis, muscle weakness, encephalopathy, a history of traumatic brain injury, a left lower leg contracture, and mild dementia. His care plan indicated a self‑care deficit related to his traumatic brain injury and contracture, and required extensive assistance from two staff with a sit‑to‑stand lift, as well as two‑person assistance with toileting and hygiene. Staff were to assist him with toileting upon waking, before and after meals, at bedtime, and during night rounds. However, during the same night shift, the CNA failed to complete resident rounds or provide toileting and incontinence care. Subsequent checks revealed that both residents had heavily saturated incontinence products and urine‑soaked beds, and the second resident had redness and moisture‑associated skin damage in the buttock area, demonstrating that his scheduled toileting and hygiene interventions were not carried out as planned.
Borrowing Controlled Medication Between Residents in Violation of Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services were delivered according to professional standards of quality when a controlled medication prescribed for one resident was taken and administered to another resident. On the night in question, a physician issued a new STAT order for Lorazepam 0.5 mg by mouth for a resident experiencing anxiety. The DON informed the physician that the ordered medication was not available in the facility for that resident, the distributing pharmacy was closed, and the resident’s family did not want the resident sent to the ER for evaluation. Despite this, the physician verbally instructed the DON that nurses were to borrow Lorazepam from another resident who had 0.5 mg Lorazepam tablets available in the facility. Following this instruction, the DON relayed to nursing staff that they were to use the other resident’s Lorazepam for the anxious resident when other comfort or distraction measures failed. An LPN subsequently removed a 0.5 mg Lorazepam tablet from the first resident’s medication card and administered it orally to the second resident. The medication was effective in relieving the second resident’s anxiety. The first resident’s controlled medication, which was ordered specifically for that resident, was therefore used for another resident, and the facility later arranged for the tablet to be replaced. Interviews with the administrator, DON, and consultant pharmacist confirmed that borrowing medications from one resident to administer to another is not acceptable clinical practice and does not meet professional standards of care. The administrator and DON acknowledged that the facility did not follow its own policies and procedures for medication ordering or resident treatment in this situation. Policy review showed that controlled substances are subject to special ordering, receipt, and recordkeeping requirements, and that when medications are not available, nursing staff are to notify the attending physician, explain the circumstances and available options, and obtain a new order while discontinuing the non-available medication. These established procedures were not followed when the staff borrowed one resident’s controlled medication and administered it to another resident.
Failure to Timely Report Allegations of Neglect from Resident Council
Penalty
Summary
A certified nursing assistant (CNA) who also served as activity staff attended and documented a resident council meeting where residents raised concerns about personal care, including issues such as residents appearing unkempt at meals and activities, exposure of body parts, and lack of privacy during care. These concerns were recorded as allegations of neglect in the meeting minutes. However, the CNA did not report these allegations to the administrator as required by facility policy, resulting in a delay in notifying the appropriate authorities. The administrator was not made aware of the allegations until five days after the meeting, and the South Dakota Department of Health (SD DOH) was notified six days after the initial allegations were made. Facility policies require that all allegations of abuse or neglect be reported to the administrator immediately, and to state authorities within 24 hours if there is no serious bodily injury. The failure to report the allegations in a timely manner led to noncompliance with both facility policy and regulatory requirements.
Failure to Provide Well-Balanced Diet and Consistent Meal Portions
Penalty
Summary
The facility failed to provide a well-balanced diet that considered the food preferences and dietary needs of its residents. Three residents expressed dissatisfaction with the meals provided, noting that they were not given choices or menus to select from, and if they refused the meal, they were only offered soup. One resident, who required a mechanical soft diet, received hard fruit, while another resident with diabetes and a consistent carbohydrate diet expressed dissatisfaction with the lack of meal options. The facility did not have an alternative menu, and residents were not consistently offered alternate meal options if they did not like what was served. The facility also failed to ensure that food portions were measured and consistent. During meal preparation, a CNA, who was not part of the regular kitchen staff, did not use measuring utensils to portion ham salad sandwiches, cucumbers with ranch, and three-bean salad. This inconsistency in portion sizes was attributed to short staffing and the CNA's nervousness due to the presence of surveyors. The dietary manager acknowledged the lack of an alternate meal and the absence of consistent portion sizes. The registered dietician, who was a contracted employee, did not visit the facility and was not informed of menu substitutions, which were made regularly due to food availability and resident preferences. The facility administrator acknowledged the staffing challenges and the need for documentation and dietician approval of substitutions. The facility's policy required residents to receive meals according to their needs and preferences, but this was not consistently followed, leading to the deficiency.
Failure to Submit PBJ Data on Time
Penalty
Summary
The provider failed to submit their Payroll Based Journal (PBJ) data for Quarter 1, 2024, to the Center for Medicare and Medicaid Services (CMS) as required. The review of the Certification and Survey Provider Enhanced Reports (CASPER) data revealed that no PBJ data was submitted for the period from October 1, 2023, through December 31, 2023. This deficiency was identified during an interview with the facility's administrator, who acknowledged the requirement to submit the data and the existence of deadlines. The administrator indicated that a vendor was responsible for tracking payroll and PBJ data, but the vendor missed the submission deadline. Further interviews with the administrator and the outsourced chief financial officer (CFO) revealed that the CFO's office was responsible for ensuring the PBJ data was submitted to CMS. A staff member from the CFO's office failed to submit the data by the deadline, missing it by one day. Both the administrator and the CFO expected the data to be submitted on time each quarter. The facility's policy, revised on January 4, 2023, stated that it is their policy to submit complete and accurate staffing information to CMS in a timely manner, but this was not adhered to for the specified quarter.
Failure to Timely Report Incidents to SD DOH
Penalty
Summary
The provider failed to provide timely and thorough notification to the South Dakota Department of Health (SD DOH) regarding incidents involving two residents. Resident 2 reported hearing a pop in her knee during a transfer, which was not immediately documented in the nurse's progress notes. Despite experiencing significant pain and swelling, the resident was not sent to the emergency room until two days later, and this information was omitted from the facility's initial and final reports to the SD DOH. The resident was eventually diagnosed with a proximal right tibial fracture, but the details of her hospital visit and diagnosis were not included in the final report. Resident 6 experienced an unwitnessed fall and was found sitting on the floor. Although she reported pain and requested medical attention, there was no immediate documentation of the fall in the nurse's progress notes. The resident's family requested an x-ray due to her complaints of pain, leading to her transfer to the emergency room. However, this information was not included in the initial report submitted to the SD DOH, and the final report was not submitted on time. The Director of Nursing (DON) admitted to not reporting the incidents in a timely manner, citing a lack of information and falling behind in reporting duties. The facility's policy requires immediate notification of the administrator and reporting to the SD DOH within two hours of forming a reasonable suspicion of a crime or injury of unknown source. The DON acknowledged awareness of these guidelines but failed to adhere to them, resulting in incomplete and delayed reporting of the incidents involving residents 2 and 6.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets as prescribed by physicians for 16 out of 21 residents. Observations revealed that meals served did not align with the approved scheduled menu items, and there was no documentation or approval from the dietician for these substitutions. All residents received the same meal without differentiation between their individually prescribed diets, which included regular, heart healthy, renal, consistent carbohydrate, and no added salt diets. The dietary manager admitted to making substitutions due to the unavailability of menu items and personal preferences of the residents, without notifying or obtaining approval from the dietician. Interviews with the registered dietician and the facility administrator confirmed that the kitchen staff did not follow the approved menus and failed to document substitutions. The dietician expressed concerns about not being informed of menu changes, and the administrator acknowledged challenges in adhering to prescribed diets due to resident preferences and complaints from elderly protection. A review of dietary orders showed that specific dietary needs were not addressed for several residents, including those requiring consistent carbohydrate, heart healthy, no added salt, and renal diets.
Failure to Implement Enhanced Barrier Precautions for Residents with Open Wounds
Penalty
Summary
The provider failed to ensure that two residents with open wounds were placed on enhanced barrier precautions (EBP). Observations revealed that staff members did not wear gowns or gloves when entering the room of a resident who required the use of a Hoyer lift for transfers. Despite the presence of a sign indicating the need for EBP and available supplies, these were not visible when the door was open. Interviews with the resident and a certified nursing assistant (CNA) confirmed that gowns and gloves were not used during transfers. The resident's electronic medical record indicated a dressing for a chronic ulcer on the right leg. Another resident with an open wound on the left foot also did not have EBP signage or supplies near the door. Staff members did not wear gowns during transfers or while providing wound care, although gloves were used during bandage changes. Interviews with a licensed practical nurse (LPN) revealed a lack of knowledge about the facility's EBP policy, with the LPN believing that EBP was only necessary for residents with multi-drug resistant organisms (MDROs). The infection control registered nurse (ICRN) also indicated that EBP was only expected for wounds with MDROs or uncontainable seepage, contrary to the facility's policy that required EBP for all residents with wounds.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The provider failed to notify the Office of the State Long-Term Care Ombudsman regarding the hospital transfers of a resident, identified as resident 13. The resident was transferred to the hospital on two occasions, once on January 29, 2024, and again on September 11, 2024. In both instances, while the resident's power of attorney (POA) was informed of the transfers, there was no documentation indicating that bed hold information was provided to either the resident or the POA. Furthermore, the facility did not send a copy of the transfer notice to the Ombudsman as required by regulations. Interviews with the facility's social services staff revealed a lack of awareness regarding the requirement to notify the Ombudsman of every hospital transfer. The social services department, responsible for these notifications, admitted to sometimes using email or phone calls for communication but did not consistently follow the protocol. The local Ombudsman confirmed not receiving notifications for the resident's transfers and had previously discussed the regulation with the facility's social services staff. Despite this, no documentation was available to verify that the Ombudsman was informed of the transfers, indicating a failure in the facility's notification process.
Failure to Renew PRN Lorazepam Order
Penalty
Summary
The provider failed to ensure that a resident's as-needed (PRN) lorazepam order was renewed for continued use beyond the 14-day limit. The resident had a physician's order for lorazepam to be administered every four hours as needed for increased anxiety and tooth pain. Despite the facility's policy requiring PRN orders for psychotropic medications to be renewed every 14 days, the order was not renewed, and the medication was administered 21 times from August 15 to September 30. The physician's response to extend the PRN order indefinitely was not documented until September 30, and the director of nursing signed it on October 2, indicating a lapse in compliance with the policy. Interviews with the director of nursing and a restorative LPN revealed that they were aware of the requirement for PRN lorazepam orders to be renewed every 14 days but were not aware that the order had not been renewed. The facility's policy on psychotropic medication use emphasizes the need for gradual dose reductions and limits PRN orders to 14 days unless a prescriber documents the rationale for extending the order. The failure to renew the PRN lorazepam order as required by policy resulted in a deficiency in the facility's medication management practices.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that a resident received food prepared to the correct temperature, as observed during a survey. The kitchen warming cabinet's thermometer was not functioning, and the temperature control dial was set at varying levels, which were not verified for accuracy. The dietary manager and cook both prepared pureed meals for the resident using warm broth, but did not recheck or reheat the food to ensure it was at a safe temperature before serving. The temperatures of the pureed foods were recorded to be below the required 135 degrees Fahrenheit, with some items as low as 107.9 degrees Fahrenheit. The facility's food preparation and service policy was not followed, as the danger zone for food temperatures was not avoided, and there was no internal thermometer in the warming cabinet to ensure safe food temperatures. The maintenance department was aware of the broken thermometer for two to three months, but a new warming cabinet was only ordered recently. The administrator was also recently informed of the issue and expected the facility's policies to be adhered to. The facility's food temperature log showed that while cooked food temperatures were documented after cooking, there was no record of temperatures being checked after pureeing and before serving.
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