Wakonda Heritage Manor

In the surveyor’s words

From the most serious findings on record at Wakonda Heritage Manor, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 13, 2025

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, interview, and policy review the provider failed to ensure two of two sampled residents (3 and 21) who were assessed and determined unable to safely use electronic lift chairs independently did not have access to the lift chair control or the chairs' power cords were unplugged or removed as directed in their assessments. Findings include: 1. Review of the provider's 11/22/24 SD DOH FRI regarding resident 3 revealed: *On 11/22/24 at 7:45 p.m. […]

• No harm, potential for more than minimal, widespreadF812Feb 13, 2025

  Based on observation, interview, and policy review, the provider failed to ensure appropriate hand hygiene and glove use was performed to prevent contamination of resident foods by two of two dietary staff (dietary manager J and medical secretary K) during one of one observed meal service in the kitchen and dining room. Findings include: 1. Observation on 2/11/25 at 11:31 a.m. in the main dining room during the noon meal service revealed: *At 11:31 a.m. dietary manager (DM) J began to prepare the resident meal plates. *DM J wore gloves while she prepared to plate the resident's food. *While wearing those same gloves, she: -Touched the surface of trays that were being reused to deliver food to the resident's tables. -Repeatedly touched the individual resident's diet cards. -Touched her cap. […]

• No harm, potential for more than minimal, patternF812Aug 18, 2022

  A. Based on observation, interview, and South Dakota Food Service Code review, the provider failed to ensure proper storage of raw and ready-to-eat meats in one of one walk-in cooler. Findings include: 1. Observation on 8/16/22 at 8:58 a.m. of the bottom shelf of the righthand side food rack in the walk-in cooler revealed: *An unopened log of ready-to-eat uncut deli ham meat and part of a 10-pound (lb.) tube of raw ground beef were on the middle tray. -Red liquid was leaking from the tube of raw ground beef onto the middle tray and onto the floor. The red liquid was touching the unopened log of ready-to-eat uncut deli ham. *The remainder of the 10lb. tube of raw ground beef was on the right tray. Interview on 8/16/22 at 9:41 a.m. […]

• No harm, potential for more than minimal, isolatedF604May 7, 2026

  Based on observation, record review, interview, and policy review, the provider failed to ensure there was documentation to support if one of one sampled resident (6) was a candidate for a restraint (a device, material, or medication used to restrict a resident's movement or access to their body to ensure safety or prevent harmful behavior) reduction, a less restrictive method, or for a restraint elimination. Findings include:1.Observation on 5/5/26 at 1:34 p.m. of resident 6 revealed she was sitting in the lounge area in a manual recliner with her feet elevated, watching a movie on the television. 2. Observation on 5/5/26 at 2:20 p.m. […]

• No harm, potential for more than minimal, isolatedF641May 7, 2026

  Based on record review, interview, and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review, the provider failed to ensure one of one sampled residents' (1) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment was accurately coded for the area of active diagnoses. Findings include:1. Review of resident 1's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. On 1/5/26 a post -traumatic stress disorder (PTSD) diagnosis was added to her diagnoses. […]