Strand-Kjorsvig Community Rest Home
Roslyn, South Dakota · CCN 435125
14 surveys since 2010. The first finding at harm level was recorded in 2015.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 68
- Surveys
- 14
- Harm or worse
- 7
- Immediate jeopardy
- 3
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
- 35
- Ownership
- Non profit - Corporation
- Chain
- Independent
- County
- Day · rural
- Medicare-certified since
- 2008
CMS ratings
- Overall
- 2
- Health inspection
- 1
- Staffing
- 5
- Quality measures
- 4
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat more weighted findings than 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
May 8, 2025
550 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 | 3.25 | 3.73 |
| Registered-nurse hours per resident day | 0.93 | — |
| Annual nurse turnover | 48.0% | 49.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $41,495 across 7 penalties
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— | L— |
| Actual harm | G28.7% | H— | I— |
| No harm, potential for more than minimal | D730.4% | E1147.8% | F313.0% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6562×
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- F6572×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- F5541×
Allow residents to self-administer drugs if determined clinically appropriate.
- F5821×
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- F6091×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
In the surveyor’s words
From the most serious findings on record at Strand-Kjorsvig Community Rest Home, in the surveyor’s own words.
- Actual harm, isolatedF689Sep 11, 2024
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, record review, interview, and policy review the provider failed to ensure the safety of one of one sampled resident (1) by staff who did not observe the resident take her medications after preparting them, which enabled the resident to not ingest multiple doses, hide those medications in her room, and then ingest those medications all at once as an act of self-harm. Findings include: 1. […]
- Actual harm, isolatedF760Sep 11, 2024
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, record review, interview, and policy review, the provider failed to follow their medications administration policy and correctly administer medication to one of one sampled resident (1) who required hospitalization after a self-harm incident. Staff were not ensuring her medications were consumed during the administration process. Findings include: 1.Review of the provider's submitted SD DOH FRI on 8/22/24 revealed: *On 8/19/24 resident 1 was transferred from the facility to the hospital for hypotension (low blood pressure) and profound weakness. *Resident was admitted to the hospital. […]
- No harm, potential for more than minimal, widespreadF835May 8, 2025
Based on interview, observation, record review, policy review, and job description review the provider failed to ensure the facility was operated under the supervision of administrator A to ensure quality management and the overall well-being of all 26 residents in the facility. Findings include: 1. Interview on 5/6/25 at 4:35 p.m. with administrator A regarding his schedule revealed: *He tried to be in the building weekly. *If he was unavailable, administrator B would be in the building once a week. *Administrator B started coming to the building once a week in January 2025. *Director of nursing (DON) C, business manager (BM) O, and dietary manger E were to be in the building on a full-time basis. 2. Interview on 5/7/25 at 9:59 a.m. […]
- No harm, potential for more than minimal, widespreadF865May 8, 2025
Based on interview and policy review, the provider failed to ensure they had an effective quality assurance and performance improvement (QAPI) program that identified and corrected quality deficiencies when they occurred throughout the facility and that performance improvement projects (PIP) had been thoroughly identified, implemented, or monitored regarding medication administration and storage, care plans, the completion of assessments, oxygen equipment use, trauma informed care, safe food storage, and infection control. Findings include: 1. Interview on 5/8/25 at 11:22 a.m. […]
- No harm, potential for more than minimal, widespreadF868May 8, 2025
Based on interview, record review, and policy review, the provider failed to ensure the quality assessment and assurance (QAA) committee had included the required members of at least one of who was the administrator, owner, a board member, or other individual in a leadership role. The provider had no evidence of the administrator, owner, board member, or other designee having attended QAA meetings at least quarterly for 15 months of meeting attendance records reviewed (February 2024 through May 2025). Findings include: 1. Interview on 5/7/25 at 10:49 a.m. […]
Read 27 findings in full →The most serious and the most recent: 27 of 68 on record.
Every survey on record
FindingsAt actual harm or above
- Aug 13, 2026Standard and complaint6 findings
- May 8, 2025Standard15 findings
- Sep 11, 2024Complaint2 findings · 2 harm
- Jan 4, 2024Standard3 findings
- Nov 17, 2022Standard3 findings
- Dec 14, 2020Infection control3 findings · 2 harm
- Jul 17, 2019Standard1 finding
- Apr 11, 2018Standard6 findings
Show the 6 earlier surveys
- Mar 1, 2017Standard2 findings
- Mar 9, 2016Standard2 findings
- Feb 11, 2015Standard16 findings · 3 harm
- Mar 12, 2014Standard4 findings
- Jan 9, 2013—1 finding
- Dec 15, 2010—4 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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