Sanford Care Center Vermillion

In the surveyor’s words

From the most serious findings on record at Sanford Care Center Vermillion, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 1, 2024

  Based on observation, interview, and record review the provider failed to provide adequate supervision for 1 of 1 resident (20) to prevent actions of self-harm. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on [DATE] at 2:12 p.m. to administrator A for F689 and director of nursing B for F689 Accidents related to the prevention of his self-harm. *Observation on [DATE] of resident 20 in his room revealed he had multiple open areas, some of which were actively bleeding on his bilateral lower legs while holding a sharp instrument. *Multiple staff interviews revealed they were aware that he had various sharp tools in his possession and used these sharps to cut himself to remove bugs he believed were under his skin. […]

• Actual harm, isolatedF689Jan 29, 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 protect the safety of two of two sampled resident (1, and 2) identified as at risk for elopement (leaving the facility without staff knowledge) who had exited a secured door and crawled out of a room window and left the building without staff supervision. Findings include:1. Review of the 11/22/25 SD DOH FRI report regarding resident 1 revealed:*Resident 1 was admitted to the facility on [DATE].*On the night of 11/2/25:-Resident 1 was wandering around at his baseline looking for exits.-At approximately 12:40 a.m. […]

• Actual harm, isolatedF684Jul 1, 2024

  Based on observation, interview, and record review the provider failed to deliver appropriate wound care, assessment and monitoring for one of one (20) sampled residents observed with wounds. Findings include: 1. Observation and interview on [DATE] at 9:29 a.m. with resident 20 revealed: *He was sitting on the edge of his bed scratching at his leg. *He had multiple open areas with some active bleeding on his bilateral lower legs and bandages on some of them. *There was a white towel under his bare feet with dried blood on it and another lying to his left with dried blood on it. *Bandage wrappers were on the floor by his feet. […]

• Actual harm, isolatedF684Feb 2, 2022

  Based on observation, interview, record review, and review of facility reported event received by the South Dakota Department of Health (SD DOH), the provider failed to ensure one of one resident (1) received care and services related to: *Pain management, including a pain identification system to accurately reflect the pain she had been experiencing. *Bathing and restorative services to promote her well-being and mobility. *Completion of grievance investigationd for the resident's concerns. *Implementation of physical therapy orders to prevent accidents and/or injuries. Findings include: 1. […]

• Actual harm, isolatedF689Feb 2, 2022

  Based on observation, interview, electronic medical record (EMR) review, and facility event report received by the South Dakota Department of Health (SD DOH) revealed the provider failed to ensure staff had updated one of one resident's (1) care plan regarding transfer needs, who sustained a fracure after a pivot transfer had been completed by one of one certified nursing assistant (CNA) H. Findings include: 1. Interviews and resident 1's EMR review completed during an onsite complaint survey on 2/2/22 revealed: *Resident 1 had an annual evaluation completed by physical therapy (PT) and occupational therapy (OT) on 12/1/21. *Their recommendations included that the resident be transferred by two staff manually or for staff to use the EZ-Stand lift. […]