Oglala Sioux Lakota Nursing Home

In the surveyor’s words

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

• Actual harm, isolatedF692Sep 12, 2024

  Licensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on observations, interviews, and record reviews; the facility failed to implement new interventions to prevent significant weight loss for 1 (Resident 20) of 4 sampled residents. The facility census was 47. Findings are: A record review of a facility policy Weight Assessment and Intervention with a revision date of March 2022 revealed the following: -Weight loss of 7.5% in three months is considered significant. A weight loss of greater than 7.5% is considered severe. -Weight loss of 10% over six months is considered significant. […]

• No harm, potential for more than minimal, widespreadF812Dec 17, 2025

  Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, record review, and interview; the facility failed to dispose of foods by their best by dates and failed to store the scoops for the flour, breadcrumbs, and sugar in a manner to prevent the potential for cross contamination. This had the potential to affect all residents who ate foods prepared in the kitchen. The facility census was 36.A.A record review of the 2022 Food Code from the United States Food and Drug Administration revealed in Annex 3 that it is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. […]

• No harm, potential for more than minimal, widespreadF812Sep 12, 2024

  Licensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews, and record reviews; the facility failed to ensure foods were disposed of or consumed prior to best-by and use-by dates, and failed to ensure food practices were conducted as required to prevent the potential for foodborne illness. This had the potential to affect all 47 residents who resided within the facility and ate foods prepared in the kitchen. A. An initial kitchen tour observation on 9/9/2024 at 9:16 AM revealed the following: In the dry food storage area: -Eleven 32-ounce containers of [NAME] Ready-care no sugar added 1.7 high calorie high protein nutrition drink with best by date of 5/7/24. -Three 4-ounce cups of 'Gelatein 20' high protein gelatin with an expiration date of 7/20/24. […]

• No harm, potential for more than minimal, widespreadF880Aug 29, 2023

  LICENSURE REFERENCE NUMBER 12-006.18C1 Based on observations, interviews and record review; the facility failed to 1) prevent potential cross contamination between clean and dirty laundry and 2) failed to ensure airflow was venting outside of the facility. This had the potential to affect all facility residents who received laundering services. The facility identified a census of 38 residents at the time of the survey. Findings are: An observation on 08/23/23 at 3:48 PM revealed H-D (Housekeeping Assistant) taking uncovered dirty laundry through the clean laundry side to the dirty side to complete sorting. There were clean linens observed in the room uncovered in a cart and on tables. The laundry room revealed there was not a door or any item to separate the clean from dirty linens. […]

• No harm, potential for more than minimal, widespreadF812Apr 8, 2021

  Licensure Reference Number: 175-NAC 12-006.11E Based on observations and interviews, the facility failed to date and label an open bag of sausage patties and a bag of ground sausage. These failures had the potential to affect all residents. Facility census was 36. Kitchen observation upon entry on 04/05/21 at 11:06 AM revealed an open bag of sausage patties and an open bag of ground sausage in a small white chest freezer, located in the main facility kitchen that had not been labeled or dated. Staff interview with the Dietary Manager on 04/05/21 at 11:06 AM confirmed the open bag of sausage patties and ground sausage had not been labeled or dated. […]