Sanford Chamberlain Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Mar 25, 2021

  Based on observation, interview, policy review, and reference source review, the provider failed to follow appropriate infection control practices for residents who were on transmission-based precautions with the potential for exposing residents and staff to serious harm including death. On 3/23/21 at 6:15 p.m. an immediate jeopardy was identified when the provider failed to ensure: A. Masks were discarded or changed when staff left a resident's room who were on transmission-based precautions (widespread). B. Goggles and or faceshields were disinfected after contact with residents on transmission-based precautions (widespread). C. Soiled and clean gowns were covered (widespread). D. […]

• Immediate jeopardy, isolatedF600Jan 9, 2025

  Based on South Dakota Department of Health (SD DOH) 1/2/25 facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to: *Ensure there was a plan of action implemented following an incident where one of one sampled resident (1) had become physically aggressive with staff and had struck another resident (2) in the face during the interaction. *Ensure one of one sampled resident (1) who had cognitive impairment was free from psychological and physical abuse by three of three certified nursing assistants (CNA) (G, K, and L) during an episode of the resident having had increased agitation and aggression. […]

• Immediate jeopardy, isolatedF600Oct 31, 2024

  Based on South Dakota Department of Health (SD DOH) 9/25/24 facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to: *Ensure the physical and psychosocial wellbeing for one of one sampled resident (1) with a history of trauma expressed feelings of fear, feeling unsafe, and suicidal thoughts that potentially increased after an unwanted entry into her room and an act of physical aggression made towards her by resident (2) who has cognitive impairment. *Ensure two of two sampled residents (2 and 3) were free from acts of verbal and physical aggression towards each other. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on 10/30/24 at 3:06 p.m. […]

• Actual harm, isolatedF600Jun 12, 2025

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, electronic medical record (EMR) review, video footage review, interview, and policy review, the provider failed to protect the resident's right to be free from physical abuse by: *One of one certified nursing assistant (CNA) (D) who responded to falling incidents with physical force and restraint for one of one sampled resident (1) with cognitive impairment. *Eight additional staff members (E, G, H, I, J, K, L, and M), identified as present at the time the physical abuse occurred, who did not intervene or report those incidents to a supervisor at the time those incidents occurred. Findings include: 1. […]

• Actual harm, isolatedF689Jun 12, 2025

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, observation, record review, and interview, the provider failed to implement, review and revise interventions to reduce the risk of falls for two of two sampled residents (1 and 2) with a history of falls and to prevent subsequent falls. Findings Include: 1. Review of the provider's 6/1/25 SD DOH FRI revealed: *[Resident 2] was found on [the] floor at 1910 [7:10 p.m.] by a CNA [certified nursing assistant] .he was attempting to self transfer out of wheelchair by [his room]. *Resident 2 sustained a closed fracture of [his] left hip. […]