Medicine Wheel Village
Eagle Butte, South Dakota · CCN 43A138
8 surveys since 2020. The first finding at harm level was recorded in 2025.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 39
- Surveys
- 8
- Harm or worse
- 1
- Immediate jeopardy
- 1
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 50
- Ownership
- Non profit - Other
- Chain
- Independent
- County
- Dewey · rural
- Medicare-certified since
- 2019
CMS ratings
- Overall
- 2
- Health inspection
- 1
- Staffing
- 5
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 48 not-for-profit facilities with fewer than 66 beds in South Dakota.
Last survey on record
Mar 25, 2026
229 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.79 | 3.73 |
| Registered-nurse hours per resident day | 1.00 | — |
| Annual nurse turnover | 31.4% | 49.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $22,636 across 1 penalty
- Special focus
- SFF Candidate
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L13.7% |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D1348.1% | E829.6% | F518.5% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F8123×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F8803×
Provide and implement an infection prevention and control program.
- F6092×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- F6582×
Ensure services provided by the nursing facility meet professional standards of quality.
- F8082×
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
In the surveyor’s words
From the most serious findings on record at Medicine Wheel Village, in the surveyor’s own words.
- Immediate jeopardy, widespreadF812Nov 20, 2025
A. Based on observation, interview, record review, manufacturer's instruction review, and policy review, the provider failed to ensure that staff followed standard food safety practices to sanitize dishware used to prepare and serve residents' food to prevent potential food-borne illness. That failure had the potential to affect all 28 residents who resided in the facility and placed them in immediate jeopardy for harm, illness, or death. Findings include: 1. Notice of immediate jeopardy of F812 was given verbally and in writing on 11/19/25 at 10:25 a.m. to administrator A regarding: *Observation on 11/19/25 at 9:00 a.m. revealed the commercial dishwasher in the kitchen was not working. *Interview on 11/19/25 at 9:20 a.m. […]
- No harm, potential for more than minimal, widespreadF732Nov 20, 2025
Based on observation, record review, and interview, the provider failed to post the required daily nursing staffing information in a location readily visible to residents, staff, and visitors that clearly reflected actual hours worked by the nursing staff for 18 of 18 days reviewed for November of 2025.Findings include: 1. Observation on 11/18/25 at 11:51 a.m. of the provider's Staffing Census Sheet revealed:*It was posted on the wall beside a door labeled staff only behind the 400 hall nurses' station.*It was hanging approximately six feet off the floor.*It included the date and resident census.*Under the Day Shift heading of that form numbers documented behind the RN (registered nurse), LPN (licensed practical nurse), CMA (certified medication aide), CNA (certified nursing assistant),… […]
- No harm, potential for more than minimal, widespreadF808Nov 20, 2025
Based on interview, observation, record review, and policy review, the provider failed to ensure nine of nine sampled residents (1, 2, 4, 5, 6, 7, 14, 17, and 18) were served foods in the appropriate form according to their physician-ordered therapeutic diets.Findings include: 1. Observation and interview on 11/18/25 at 12:01 p.m. with dietary aide T revealed: *He served whole chicken breasts, whole slices of ham, and cubed pieces of ham that were approximately one-inch pieces. *He did not have residents' diet cards to reference what the residents' ordered diets were. […]
- No harm, potential for more than minimal, widespreadF800Oct 3, 2024
Based on observation, interview, record review, and policy review, the provider failed to serve a well-balanced diet that: A. Considered the food preferences for 3 of 3 sampled residents (6, 13, and 16). B. Contained dietician-approved nutritional equivalent food substitutions for 21 of 21 sampled residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21) for one of one observed meal service. Findings include: 1. Observation and interview on 10/1/24 at 9:09 a.m. […]
- No harm, potential for more than minimal, widespreadF851Oct 3, 2024
Based on Certification and Survey Provider Enhanced Reports (CASPER) reporting data review, interview, and policy review, the provider failed to ensure their Payroll Based Journal (PBJ), (information of the provider's daily staffing hours for the appropriate care of the residents) had been complete and the data had been submitted to the Center for Medicare and Medicaid Services (CMS) for one of four quarters (Quarter 1, 2024). Findings include: 1. Review of the provider's CASPER reporting data revealed no PBJ data had been submitted for the time period of October 1, 2023, through December 31, 2023. Interview on 10/1/24 at 3:47 p.m. […]
Read 20 findings in full →The most serious and the most recent: 20 of 39 on record.
Every survey on record
FindingsAt actual harm or above
- Mar 25, 2026Complaint2 findings
- Nov 20, 2025Standard and complaint14 findings · 1 harm
- Oct 3, 2024Standard and complaint8 findings
- Aug 3, 2023Standard3 findings
- Apr 6, 2022Standard2 findings
- Feb 17, 2021Infection control1 finding
- Oct 16, 2020Infection control1 finding
- Feb 28, 2020Standard and complaint8 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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