Flandreau Santee Sioux Tribe Care Center

In the surveyor’s words

From the most serious findings on record at Flandreau Santee Sioux Tribe Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 30, 2025

  Based on review of the South Dakota Department of Health (SD DOH) complaint intake report review, interview, security video review, record review, and policy review, the provider failed to ensure one of one certified nursing assistant (D) safely transported one of one sampled resident (1) in her wheelchair who fell out of her wheelchair and fractured her hip.Findings include:1. Review of the 9/10/25 SD DOH complaint intake report revealed the provider and Adult Protective Services (APS) reported resident 1 fell from her wheelchair to the SD DOH.The SD DOH facility-reported incident (FRI), received on 8/30/25, indicated that on 8/29/25 at around 8:00 p.m., while certified nursing assistant (CNA) D was transporting two residents in their wheelchairs, resident 1's wheelchair brake caught on… […]

• Actual harm, isolatedF689Dec 31, 2024

  A. Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, observation, record review, and policy review the provider failed to effectively implement and follow their policy for 5 of 8 sampled residents (1, 2, 4, 5, and 6) who smoked and accurately assess 1 of 1 sampled resident (3) who vaped. Findings include: 1. Review of the provider's SD DOH FRI regarding resident 1 revealed: *On 11/25/24 during her weekly skin check she was observed to have what appeared to be a cigarette burn on her abdomen. -That wound measured 0.6 centimeters (cm) x 1cm x 0.1cm. -A physician's order was obtained to apply bacitracin to wound once daily and cover with a band-aid. Change daily. Leave uncovered during bath/shower. […]

• Actual harm, isolatedF689Oct 22, 2024

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and observation, the provider failed to prevent an injury to one of one sampled resident (1) who developed a skin burn wound on her abdomen from hot food that was prepared for her by staff in a microwave. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 10/10/24 SD DOH FRI regarding resident 1 revealed: *On 9/26/24 at 8:30 p.m. […]

• No harm, potential for more than minimal, patternF812Aug 7, 2025

  Based on observation, interview, record review, and policy review, the provider failed to follow food safety standards by not having monitored and documented food temperatures for 40 of 192 meals served to residents from 5/1/25 through 8/3/25. Findings include:1. Observation and interview on 8/5/25 at 10:15 a.m. with cook E in the kitchen revealed:*A three-ring binder on top of the steam table labeled dinner temp book.*Cook E stated kitchen staff were to document food temperatures in the temp book.*He stated there was a temp book for breakfast, dinner, and supper.*He knew food had to be heated to certain temperatures.*He agreed there were some food temperatures that were not documented in the dinner temp book. […]

• No harm, potential for more than minimal, patternF656Aug 6, 2024

  Based on observation, interview, record review, and policy review, the provider failed to ensure care plans reflected the current individualized activities of daily living (ADL) and pressure ulcer prevention and treatment needs of two of two sampled residents (1 and 2). Findings include: 1. Observation on 8/6/24 at 1:04 p.m. of resident 2's room revealed her bed had an air mattress and positioning cushions on it. Observation and interview on 8/6/24 at 2:12 p.m. with resident 2 while in her room revealed she: *Was seated in a specialized wheelchair. Her legs were elevated and rested on pillows. *Stated she repositioned herself in bed frequently and could achieve several different positions while in her wheelchair. […]