White River Health Care Center

In the surveyor’s words

From the most serious findings on record at White River Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Nov 18, 2024

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, electronic medical record (EMR) review, observation, interview, and policy review, the provider failed to ensure one of one resident (1) was not abused by staff registered nurse (RN) (C), licensed practical nurse (LPN) (D), and certified nurse aide (CNA) (E) during the administration of a medication injection. Findings include: 1. Review of the provider's 11/8/24 SD DOH FRI revealed: *Resident 1 had a recent visit to the tribal Indian health service (IHS) emergency room (ER) on 10/23/24 related to increased aggressive behaviors toward other residents and staff. […]

• No harm, potential for more than minimal, patternF755Jul 9, 2026

  Based on observation, interview, and policy review, the provider failed to ensure hand hygiene, glove use, and medication handling according to the pharmacy instructions by one of one observed licensed practical nurse (LPN) (K) during medication preparation and administration of one of one sampled resident's (33) medications, including divalproex, a seizure medication with handling precautions. Findings include:1. Observation on 7/8/26 at 4:29 p.m. with LPN K while she prepared and administered resident 33's medications revealed LPN K removed a Flomax (a medication used to treat symptoms of an enlarged prostate)0.4 milligram (mg) capsule from the medication bubble package (a tool that organizes pills by the day and time) into her bare hand and placed that capsule on a tissue on the… […]

• No harm, potential for more than minimal, isolatedF732Jul 9, 2026

  Based on observation, interview, and policy review, the provider failed to ensure the daily nurse staffing information, including the total number and the actual hours worked by registered nurses, licensed practical nurses, licensed vocational nurses, and certified nursing assistants per shift, was posted in a location visible and accessible to residents, staff, and visitors. Findings include: 1. Observation on 7/7/26 at 10:00 a.m. of a white dry-erase board on the wall across from the nurses' station revealed the staff had written the date, resident census, and number of nursing personnel working. […]

• No harm, potential for more than minimal, isolatedF759Jul 9, 2026

  Based on observation, interview, record review, and policy review, the provider failed to ensure a medication error rate of less than 5 percent related to Flomax (a medication used to treat an enlarged prostate) was administered on time, and was administered according to the physician's order for one of one observed resident (33) by licensed practical nurse (LPN) (K,) and sodium chloride (a medication to treat low sodium levels in the blood) was administered on time for one of one observed resident (23) by LPN (K). Those observed errors resulted in a medication error rate of 6.9%. Findings include:1. Observation and medication administration record (MAR) review on 7/8/26 at 4:02 p.m. […]

• No harm, potential for more than minimal, isolatedF880Jul 9, 2026

  Based on observation, interview, and policy review, the provider failed to ensure the staff followed standard infection prevention and control practices by one of one observed contracted travel certified nursing assistant (CNA) (J), and one of one observed CNA (E) who did not perform hand hygiene before and after glove use while providing personal cares for one of one sampled resident (2). Findings include:1. Observation on 7/7/26 at 4:08 p.m. in resident 2's room of LPN D, contracted travel CNA J, and CNA E providing personal cares for resident 2 revealed resident 2 was incontinent (involuntary urine or bowel leakage) of bowel. LPN D and contracted travel CNA J each put on a gown, performed hand hygiene, and put on a pair of gloves. LPN D positioned resident 2 onto his right side. […]