Kadoka Nursing Home

In the surveyor’s words

From the most serious findings on record at Kadoka Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 16, 2025

  Based on observation, record review, interview, and policy review, the provider failed to ensure: *One of one low-temperature dishwasher consistently met the required minimum wash and rinse temperatures for proper sanitation. *Temperature monitoring and documentation was completed consistently for one of one dishwasher temperature logs. Findings included: 1. Observation on 4/14/25 at 12:35 p.m. in the kitchen revealed: *The mechanical dishwashing machine had a label on it that read: -Wash Temperature 120 degrees F [Fahrenheit] minimum. […]

• No harm, potential for more than minimal, widespreadF812Dec 20, 2023

  Based on observation, interview and policy review the provider failed to ensure: *One of one kitchen was maintained in a clean and sanitary manner. *Food was stored and labeled safely. Findings include: 1. Observation and interview on 12/18/23 at 10:15 a.m. with dietary manager E while in the kitchen revealed: *A large, thick, white, and brown circle under the dishwasher. *The gas stovetop and burners had dried, burnt food particles on it. *The space between the stovetop and the grill had grease build-up and burnt food particles. *Under the stove and the prep table the floor had a thick build-up of dust, grease and visible chunks of food. […]

• No harm, potential for more than minimal, isolatedF812Jul 23, 2026

  Based on observation, interview, kitchen task checklist review, and policy review, the provider failed to ensure standard food safety practices were followed regarding two of two observed freezers in the kitchen galley with food items in them that were not stored and labeled according to the provider's policy and one of one ceiling fan in the kitchen where residents' food was prepared that was on and not clean to prevent food contamination.Findings include:Observation on 7/21/26 at 10:30 a.m. in the kitchen galley revealed there were two freezers. Inside the freezers, there were clear, unlabeled, and undated plastic bags that contained diced chicken, rhubarb stalks, and hot dogs. There were two additional unlabeled and undated plastic bags containing unknown food items. […]

• No harm, potential for more than minimal, isolatedF657May 27, 2026

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, observation, and policy review, the provider failed to review and revise one of one sampled resident's (1) care plan (personalized plan that addresses a resident's care needs, goals, and interventions) after the resident eloped (left the facility without staff knowledge).Findings include:1. Review of the provider's 3/9/26 SD DOH FRI revealed that on 3/8/26 at 2:10 p.m., resident 1 opened the front entrance door of the facility causing the door's alarm to sound. Certified nurse aide (CNA) F responded to the alarm. She saw the front door closing behind resident 1. CNA F redirected the resident back inside the facility and settled her back into her room. At 2:30 p.m. […]

• No harm, potential for more than minimal, isolatedF658Apr 16, 2025

  Based on observation, interview, record review, and policy review, the provider failed to adhere to professional standards of care by not ensuring medications were taken by four of four observed residents (3, 9, 14, and 19) at the time those medications had been administered by one of one unlicensed medication aide (UMA) (I) and one of one licensed practical nurse (LPN) (J). Findings include: 1. Observation and interview on 4/14/25 with resident 14 in the dining room revealed: *At 5:30 p.m. a blue, oval-shaped pill, and a round salmon-colored pill were in a medication cup on the dining table in front of the resident. *Resident 14 sat between two female residents at that table. -The table was located near the entrance to the kitchen and around the corner from the medication cart. […]