St William's Care Center

In the surveyor’s words

From the most serious findings on record at St William's Care Center, in the surveyor’s own words.

• Actual harm, patternF600Jul 24, 2024

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, record review, and policy review, the provider failed to protect three of five sampled residents (2, 3, and 4) from mistreatment, intimidation, verbal abuse, and physical abuse by one of one certified nurse assistant (J). Findings include: 1. Review of the provider's FRI online report submitted to the SD DOH on 6/30/24 revealed: *Resident 2 was not feeling well on the evening of 6/29/24. […]

• Actual harm, isolatedF686Feb 19, 2026

  Based on observation, interview, record review, and policy review, the provider failed to implement pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) prevention interventions for one of one sampled resident (3) who was identified at risk for developing a pressure ulcer and developed an unstageable (wound bed not visible due to covering, such as debris, dead tissue, scabbing, or a non-removable dressing) pressure ulcer to her left heel while under their care. Findings include:1. Observation on 2/10/26 at 10:57 a.m. of resident 3 in the dining room revealed that she was sitting upright in her wheelchair. She was not wearing heel boots (a cushioned boot used to reduce pressure from a person's heel. 2. Observation on 2/10/26 at 2:21 p.m. […]

• Actual harm, isolatedF600Oct 2, 2024

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI] report, interview, record review and policy review the provider failed to prevent staff to resident sexual abuse from occurring for one of one resident (29). Findings include: 1. Review of the SD DOH FRI report for resident 29 revealed: *On 9/21/24 at 11:35 p.m. certified nursing assistants [CNAs] reported to licensed practical nurse (LPN) H that resident 29 was complaining of CNA M being rough after she had used the bathroom and was being cleaned up. *LPN H assessed resident 29 in her room. *Administrator A and director of nursing (DON) B were notified. *Resident 29's power of attorney (POA) was notified. *Resident 29's primary physician was notified. […]

• Actual harm, isolatedF609Aug 10, 2023

  Based on observation, interview, record review, and policy review the provider failed to ensure that two of two sampled residents (27 and 32) had an investigation completed following falls with injuries. Findings include: 1. Observation and interview on 8/7/23 at 4:25 p.m. with resident 27 while he was sitting in his wheelchair revealed: *He had fallen a few times but could not remember when. *He used his wheelchair for mobility. *He had worn glasses and was hard of hearing. Review of resident 27's electronic medical record (EMR) revealed: *On 5/26/23 at 3:30 p.m. […]

• Actual harm, isolatedF610Aug 10, 2023

  Based on observation, interview, record review, and policy review the provider failed to ensure that two of two sampled residents (27 and 32) who had falls with injuries were reported to the South Dakota (SD) Department of Health after falls with injuries. Finding include: *One of one sampled resident 27 required a transfer to the emergency room for further evaluation and treatment. *One of one sampled resident 32 had sustained injuries to her left leg from improper use of the sit-to-stand mechanical lift. *Refer to F609.