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 Tekakwitha Living Center during CMS and state inspections, most recent first.
Several cognitively intact residents were not informed of meal options in advance and were not consistently asked about their meal preferences, as menu postings and communication were lacking in one dining area. Additionally, the dietary manager was reported to have yelled and used foul language in front of residents and staff, creating an environment that was not respectful or dignified.
The facility did not maintain a clean and homelike environment, as evidenced by repeated observations of food debris, dirty tables, stained carpets, chipped paint, torn flooring, and a persistent ceiling leak with standing water in a basin. Staff interviews revealed confusion about cleaning responsibilities, especially after evening meals, and maintenance issues were not promptly resolved, leading to ongoing unclean and damaged conditions in resident areas.
The facility did not consistently follow food safety standards, as evidenced by improper storage of food items on the floor, undated and unlabeled open food in the freezer, and incomplete temperature and cleaning logs. Ongoing leaks from the dishwasher and sink were left unresolved for years, with buckets of discolored liquid and sludge found beneath the equipment. Staff interviews confirmed awareness of these issues, and facility policies requiring proper storage, labeling, and equipment monitoring were not followed.
A resident developed facility-acquired pressure ulcers due to inadequate care and failure to adhere to preventive measures. Despite being at high risk, the resident was not consistently repositioned, and necessary interventions like an air mattress and appropriate heel protectors were delayed. Staff acknowledged the ulcers were avoidable, and the facility's policy on regular repositioning and skin monitoring was not followed.
A resident with Alzheimer's disease engaged in woodworking activities in a facility's basement, leading to multiple accidents due to inadequate supervision. Despite a care plan requiring supervision while using an electric saw, the resident was often unsupervised, resulting in injuries. Staff interviews revealed a lack of ongoing assessments and inconsistent implementation of safety measures, contributing to repeated accidents.
The facility failed to have a qualified infection preventionist (IP) for at least two years. The DON had been acting as the IP without proper training or certification. Attempts to train a registered nurse for the role were unsuccessful, and the infection control program's records lacked a qualified IP's signature for annual reviews.
The facility failed to remove expired medications from the medication room, cart, and treatment cart in the north hall. An RN found expired aspirin, hydrogen peroxide, rubbing alcohol, oral glucose gel, Heparin syringes, Prevnar 13 vaccines, hand sanitizer, white petroleum packets, and Vaseline gauze. The DON admitted to not keeping up with removing expired medications, and pharmacy audits did not include checking for expired items, contrary to the facility's policy.
The facility failed to follow food safety guidelines, with incomplete temperature documentation for refrigerators and freezers, and improper food storage and labeling in the main kitchen. Despite staff education, logs were not consistently filled out, and outdated food items were found. The facility's policies on food storage and temperature monitoring were not adhered to.
Two nurses failed to follow appropriate infection control measures during pressure ulcer dressing changes for a resident on enhanced barrier precautions (EBP). LPN G did not perform hand hygiene between glove changes and transported the treatment cart into the resident's room. RN F did not change gloves or wash her hands after removing the resident's boot and sock before applying a new dressing. The DON confirmed the treatment cart should not have been taken into the room, and the facility's policies emphasized the importance of hand hygiene and barrier precautions.
A resident was transferred to the hospital after a fall, but the facility failed to provide a bed-hold notice to the resident or their representative. Staff interviews revealed confusion about who was responsible for notifying the resident, and the facility's policy lacked clarity on the timing of such notifications.
The facility failed to update care plans for two residents, one with a pressure ulcer and another with leisure interests in woodworking and driving a golf cart. Resident 23's care plan lacked documentation of interventions like an air mattress and wound care, while Resident 10's care plan did not address his leisure activities or include his supplemental woodworking plan in the EMR. These omissions led to deficiencies in meeting the residents' current needs.
Failure to Promote Resident Self-Determination and Maintain Respectful Environment
Penalty
Summary
The facility failed to promote residents' right to self-determination and maintain a respectful environment, as evidenced by multiple observations and interviews. Four cognitively intact residents who dined in the east dining room reported being unaware of planned meal options or available food choices until meal service began. Observations confirmed that menu choices were not posted in the east dining room, and staff did not consistently ask residents about their meal preferences prior to serving. There was also confusion among staff regarding who was responsible for offering meal choices, and meal identification tray cards were not being used as required. Additionally, the dietary manager (DM) was reported by staff and residents to have yelled and used foul language in front of residents and other staff members. Several staff members described incidents where the DM was verbally aggressive, used profanity, and displayed disruptive behavior such as slamming items. Residents witnessed these outbursts, which made them feel uncomfortable and concerned for the staff involved. Some staff reported these incidents to management, while others did not, and there was a lack of documentation regarding the facility's response to these events. The facility's policies require that all residents be treated with kindness, respect, and dignity, and that staff model effective communication. Despite these requirements, the DM's behavior and the lack of clear communication regarding meal choices resulted in residents not being fully supported in exercising their rights. The events described involved residents who were cognitively intact and able to express their preferences and concerns, yet their rights to self-determination and a respectful environment were not upheld.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as required, with multiple observations of uncleanliness and disrepair in resident common areas. Surveyors observed food crumbs and debris on dining room floors, dirty tables, and persistent coffee-like stains on countertops. A pink foot soak basin with discolored standing water was repeatedly seen on the floor, collecting water from a ceiling leak, and missing ceiling tiles were noted around the leak. Stains and damage were also observed on carpeting throughout hallways and common areas, including large, visible stains and areas with missing or chipped paint, torn flooring, and missing trim. Interviews with dietary and housekeeping staff revealed confusion and lack of clarity regarding cleaning responsibilities, particularly after the evening meal. Dietary staff indicated they were responsible for wiping tables and sweeping floors after supper, while housekeeping staff stated they cleaned tables and floors after breakfast and lunch but were unsure who was responsible in the evenings. Maintenance staff acknowledged awareness of the roof leak and indicated plans to address it, but the issue persisted over several days as evidenced by repeated observations of the basin collecting water. A review of facility policies confirmed the expectation for a clean, orderly, and safe environment, with specific routines for cleaning floors, carpets, and congregate areas, and requirements for prompt attention to spills and damage. Despite these policies, the facility did not ensure that cleaning and maintenance tasks were completed as required, resulting in ongoing environmental deficiencies in areas frequented by residents.
Failure to Follow Food Safety Standards and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to food safety standards regarding the storage, labeling, and monitoring of food and equipment in the kitchen. Observations revealed multiple food items, such as boxes of juice and a dented soup can, stored directly on the floor in the storage room. Several open and undated bags of food, including fish patties, steak patties, cheese omelets, and mini corn dogs, were found in the walk-in freezer. Additionally, a puddle of liquid was observed on the floor inside the walk-in refrigerator, creating a slipping hazard. Temperature logs for refrigeration units and chemical sanitizing dishwashers showed missing documentation on several dates, indicating a lack of consistent monitoring. Further inspection of the dishwashing area revealed ongoing equipment issues, including a leaking dishwasher and a leaking sink drain, both of which had been present for an extended period. Buckets containing discolored liquid and sludge were found under the dishwasher and sink, and hard water stains were noted on the floor. Staff interviews confirmed that the dishwasher and sink had been leaking for up to three years, with maintenance and dietary staff aware of the issues but not resolving them. The dietary manager was responsible for posting and monitoring cleaning and task checklists, but documentation was incomplete or missing for several days, indicating lapses in routine cleaning and maintenance procedures. The facility's policies required that food be stored off the floor, covered, labeled, and dated, and that refrigeration and dishwashing equipment be regularly monitored and documented. However, these standards were not consistently followed, as evidenced by the improper storage of food, lack of labeling and dating, incomplete temperature and cleaning logs, and unresolved equipment leaks. These deficiencies were identified through complaint report review, direct observation, staff interviews, and policy review.
Failure to Prevent Facility-Acquired Pressure Ulcers
Penalty
Summary
The provider failed to prevent a resident from developing facility-acquired pressure ulcers. The resident, identified as having a moderate to high risk for pressure sores, developed a pressure ulcer on the heel and sacrum. Interviews with staff revealed that the resident was not consistently repositioned, which contributed to the development of these ulcers. The Director of Nursing (DON) and other staff acknowledged that the pressure ulcers were avoidable and that interventions such as changing the bed and mattress, and using appropriate heel protectors, were not implemented in a timely manner. Observations and interviews indicated that the resident's care was inadequate, with issues such as the removal of a 'turn and reposition clock' by CNAs and the late implementation of an air mattress. The resident's sacral ulcer worsened significantly over time, indicating a lack of effective preventive measures. The facility's policy required regular repositioning and immediate reporting of skin changes, which were not adhered to, leading to the resident's condition worsening.
Inadequate Supervision of Resident's Woodworking Activities
Penalty
Summary
The provider failed to implement effective precautions and interventions to ensure the safety of a resident with Alzheimer's disease who engaged in woodworking activities in the facility's basement. Despite having a care plan that required supervision while using an electric saw, the resident was often unsupervised, leading to multiple accidents. The resident had a history of cognitive decline and had suffered several injuries, including cuts and bruises, while working with woodworking equipment. Interviews with staff revealed that the resident was assessed for his ability to safely pursue woodworking activities, but ongoing assessments were not conducted despite his Alzheimer's diagnosis. The resident's care plan included interventions such as using a walkie-talkie to communicate with staff and wearing safety gloves, but these measures were not consistently followed. Staff members acknowledged that the resident often worked unsupervised and that there was no video monitoring in place to ensure his safety. The facility's policy on resident safety during leisure tasks was not effectively implemented, as evidenced by the lack of follow-up assessments and incident analyses for the resident's accidents. The resident's electronic medical record documented several incidents of injury, but no incident reports were provided by the facility. The failure to adequately supervise and assess the resident's woodworking activities contributed to repeated accidents and injuries.
Lack of Qualified Infection Preventionist
Penalty
Summary
The provider failed to designate a qualified infection preventionist (IP) for the facility, as revealed through interviews and record reviews. The Director of Nursing (DON) had been acting as the IP for the past two years without the necessary training or certification. Despite attempts to have a registered nurse complete the required program, the facility had not succeeded in appointing a qualified IP. The infection control program's records showed that the annual review signature form had not been signed by a qualified IP for at least two years, indicating a lack of compliance with infection prevention and control requirements.
Expired Medications Not Removed from Storage Areas
Penalty
Summary
The facility failed to ensure that expired medications were removed from the medication room, medication cart, and treatment cart in the north hall. During an observation and interview with a registered nurse, it was found that several expired medications were present, including aspirin, hydrogen peroxide, isopropyl rubbing alcohol, oral glucose gel, Heparin injectable syringes, Prevnar 13 vaccines, hand sanitizer, white petroleum packets, and Vaseline gauze. The registered nurse acknowledged that medication expiration dates should have been checked before administration and that expired medications should have been removed. The director of nursing admitted to not keeping up with the removal of expired medications from the medication rooms and carts, although they should have been removed and destroyed. It was also confirmed that pharmacy audits were conducted, but these audits did not include checking for expired medications. The facility's policy on medication storage stated that no discontinued, outdated, or deteriorated drugs or biologics should be available for use and that all such drugs should be destroyed. However, the pharmacy audits conducted in May and June did not address outdated medications.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The provider failed to adhere to necessary food safety guidelines in the main kitchen, as observed during a survey. The documentation for refrigerator and freezer temperatures was incomplete, with missing entries for several days in April, May, June, and July 2024. Despite regular education provided to staff on the importance of temperature documentation, the logs were not consistently filled out. Interviews with kitchen staff and the dietary manager confirmed the lack of documentation, and verbal warnings had been issued to staff who failed to comply. The facility's policy required daily monitoring and recording of temperatures, but this was not followed. Additionally, food storage and labeling practices were inadequate. Observations revealed improperly stored and labeled food items, including opened packages without use-by dates and outdated food in refrigerators. Uncovered food items were also found, and the dietary manager acknowledged that these items should have been covered, dated, and discarded if outdated. The facility's food storage policy required proper labeling, dating, and covering of food items, but these procedures were not consistently implemented, leading to the presence of outdated and improperly stored food.
Infection Control Deficiency in Wound Care
Penalty
Summary
The provider failed to ensure appropriate infection control measures during pressure ulcer dressing changes for two nurses, LPN G and RN F. During an observation of LPN G's wound care for a resident on enhanced barrier precautions (EBP), it was noted that she prepared wound care materials at the nurses' station without gloves, transported the treatment cart into the resident's room, and did not perform hand hygiene between glove changes. She applied a soaked gauze and a sacral dressing to the resident's wound without washing her hands or using hand sanitizer after cleaning the wound. Similarly, RN F, while changing a heel dressing for the same resident, did not change gloves or wash her hands after removing the resident's boot and sock before applying a new dressing. She also expressed uncertainty about whether the treatment cart should have been taken into the room for a resident on EBP. The Director of Nursing (DON) expressed frustration over the nurses' failure to perform hand hygiene, which is considered standard care, and confirmed that the treatment cart should not have been taken into the resident's room. The facility's undated pressure ulcer prevention and wound care policy emphasized the importance of meticulous handwashing and maintaining a clean environment during dressing changes. The enhanced barrier precautions policy outlined the need for gown and glove use during high-contact resident care activities for residents with wounds, highlighting the risk of transmission of multidrug-resistant organisms (MDROs).
Failure to Provide Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The provider failed to provide bed-hold notices to a resident and/or their representative during a transfer to the hospital. The deficiency was identified for one of two sampled residents. The resident, who had fallen and sustained a fractured right femoral head, was transferred to the emergency room and subsequently to a local hospital for further evaluation. Despite the transfer, there was no written notification provided to the resident or her representative regarding the bed hold policy. Interviews with staff revealed a lack of clarity and execution in the notification process. RN F admitted to not notifying the resident or their representative about the bed hold notice, and the charge nurse was expected to handle this task. The director of nursing and the administrator confirmed that the charge nurse should have completed the bed hold form at the time of transfer, but this was not done. The facility's bed hold policy, which was undated, did not specify when the notification should be given, contributing to the oversight.
Deficiencies in Care Plan Updates for Residents with Pressure Ulcer and Leisure Interests
Penalty
Summary
The provider failed to ensure that the care plans for two residents were revised to reflect their current needs. Resident 23, who had a pressure ulcer, was observed in bed with interventions such as an air mattress and bunny boots that were not documented in his care plan. Interviews with staff revealed that changes to his bed and mattress were made due to issues with his previous bed, but these changes were not updated in his care plan. Additionally, interventions for his wound care were not noted in the care plan, despite changes being made to improve his condition. Resident 10, who had leisure interests in woodworking and driving a golf cart, did not have these activities addressed in his comprehensive care plan. Although he had a supplemental paper care plan for woodworking, it was not included in the electronic medical record (EMR). Interviews with staff indicated that his ability to safely operate the golf cart and pursue woodworking activities had been assessed, but these assessments were not reflected in his comprehensive care plan. Furthermore, his care plan did not address his goals, preferences, strengths, weaknesses, or needs related to these leisure activities. The facility's policy on care plans requires that they include measurable objectives and timetables to meet the resident's needs and reflect current standards of practice. However, the care plans for both residents 23 and 10 were not updated to include significant changes in their care and activities, leading to deficiencies in meeting their current needs. The interdisciplinary team responsible for reviewing and updating care plans did not ensure that these updates were made, resulting in a failure to provide comprehensive and individualized care for these residents.
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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 Sisseton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Browns Valley Health Center | 11.9 mi | — | 7 | 1 |
| Wilmot Care Center Inc | 19.9 mi | — | 0 | 0 |
| Strand-kjorsvig Community Rest Home | 24.5 mi | — | 0 | 0 |
| Traverse Care Center | 28.5 mi | — | 7 | 0 |
| St Gerard's Community Of Care | 28.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.