Good Samaritan Society Sioux Falls Center, which was recently removed from a remedial program for nursing homes. (John Hult/South Dakota Searchlight)
Six of South Dakota’s 96 nursing homes are on the newest monthly federal list of the nation’s worst-rated care facilities.
Five of the facilities are eligible for a special program to improve quality of care through increased regulatory oversight, and one is already in the program.
The eligible South Dakota facilities as of the April report from the Centers for Medicare and Medicaid Services are Avantara Norton in Sioux Falls, Riverview Healthcare Center in Flandreau, Good Samaritan Society Sioux Falls Village, Lake Andes Senior Living and Wilmot Care Center.
One facility, Dells Nursing and Rehabilitation Center in Dell Rapids, has been in the Special Focus Facility program for nearly two years. Good Samaritan Society Sioux Falls Center — separate from the society’s similarly named Sioux Falls Village — graduated in July 2023, after spending 27 months in the program.
Nursing homes are identified by the state as special-focus facilities based on their last three standard health survey inspections. Special-focus facilities must meet more stringent criteria two times in a row to be eligible for graduation. Dells Nursing and Rehabilitation Center did not pass its most recent inspection in January, so it will restart the process toward graduation.
Because the number of special-focus facilities is capped, eligible facilities — even those that have earned CMS’ lowest ratings for quality — can’t be named a special-focus facility until other homes in the same state already in the program are terminated from Medicare and Medicaid or improve and “graduate” from the program.
That’s a process that can take several years. As a result, there are homes in each state that are eligible for special-focus status due to ongoing quality-of-care problems, but can’t enroll in the program. It’s also why two of the five eligible South Dakota facilities have waited more than three years as candidates: Avantara Norton and Riverview Healthcare Center.
Typically, the homes that are deemed eligible for special-focus designation have about twice the average number of violations cited by inspectors; they have more serious problems than most other nursing homes, including harm or injury to residents; and they have an established pattern of serious problems that has persisted over a long period of time.
Facility summaries
The five South Dakota homes eligible for inclusion in the Special Focus Facility program all have 1-out-of-5-star ratings from CMS.
The federal agency penalizes and fines nursing homes for serious citations or if the facility fails to correct a citation for a long period of time. A portion of fines collected are returned to the state, which can be reinvested to support nursing home residents and improve their quality of life and care.
Following are summaries of the problems cited at each of those facilities, along with the one South Dakota facility already in the program and a facility that graduated in 2023.
Dells Nursing and Rehab Center: The 48-bed facility, operated as a for-profit corporation, has participated in the SFF program for 22 months. The home has been cited for 19 deficiencies since the start of 2024 and has been fined $67,773 in the last three years.
It was flagged for “immediate jeopardy” to its residents in February 2024 after a resident left the facility without staff knowledge for a third time in a year. The last two times, the patient was found wandering the facility parking lot. The first time, in June 2023, the resident was found a mile away. An alarm was set on the resident’s tracking device to alert staff if the resident left the facility. The home was cited for 19 deficiencies since the beginning of 2024, with about $67,800 in fines during that time.
The facility was found noncompliant for infection control in its latest state survey inspection report in March.
Avantara Norton: The 110-bed facility in Sioux Falls is owned by for-profit company Legacy Healthcare. The home has been cited for 15 deficiencies since the start of 2024 and has been fined $175,402 in the last three years. It’s been a special focus candidate for 39 months.
The home received a serious deficiency in its November 2024 report for failing to protect a resident from neglect by a certified nursing assistant. The resident was not cared for in a timely manner, possibly contributing to two skin sores. The staff member was disciplined and educated, according to the report.
The facility’s most recent inspection report in March included several citations, including a quality of life citation affecting several residents primarily due to poor call light response times and aid. In an interview, one resident told the state inspector “no one cared” at the facility, that he did not receive timely showers or help out of bed, and that staff response times to call lights vary from five minutes to three hours.
He and other residents said they would sometimes have to call the receptionist’s desk on the phone to ask her to send staff for help. Residents also said there were not enough staff to meet their needs, according to the report. Staff confirmed they occasionally experience staffing shortages. Administrators said they would require regular call light audits to review progress.
The facility’s most recent complaint inspection in April found a registered nurse was stealing controlled substances from the facility for four months. The nurse tested positive for hydrocodone and oxycodone and admitted to the accusation.
Riverview Healthcare Center: The 49-bed facility in Flandreau, owned by for-profit company EmpRes Healthcare Management, has been cited for eight deficiencies since the beginning of 2024, including an “immediate jeopardy” flag for failing to respond and report abuse allegations. It has been fined $81,568 in the last three years and been a special focus candidate for 37 months.
According to the January 2025 report, a certified nursing assistant kicked a resident in the shin twice and covered another resident’s mouth with a washcloth to quiet them. Several staff reported their suspicions but the staff member continued working and the nursing home did not conduct an investigation or follow its abuse and neglect policy. According to the facility’s correction plan, the staff member was put on administrative leave, the administration educated staff on its abuse and neglect policy, and staff interviewed residents randomly and on a weekly basis to hear concerns or look for signs of abuse and neglect.
In its most recent state recertification inspection report from February, citations included improper ulcer prevention and improper food preparation and storage. In a complaint inspection in February, the facility was cited for quality of care problems and failing to provide a safe, clean environment, among other citations. An inspector also found hazards including rusty, exposed edges of an emergency exit door, chunks of missing floor, baseboards, wallpaper and paint, and a hole in a ceiling.
Good Samaritan Society Sioux Falls Village: The 177-bed nonprofit facility in Sioux Falls has been a special-focus candidate for eight months. The home has been cited three times since the start of 2024 and fined $67,504 in the last three years. It has been a special focus candidate for nine months.
The facility was flagged for “immediate jeopardy” to resident health in its June 2024 report because a resident left the facility without staff’s knowledge twice within a few days and because another resident fell multiple times without receiving prompt assistance.
In its most recent complaint inspection report in September, the facility was investigated for alleged abuse and neglect. A staff member was “written up” for lack of care and false charting, for saying they’d checked in on residents and changed them when they hadn’t. The staff member’s charting will be audited, administration said in their correction plan, and the facility will randomly audit to ensure residents received scheduled baths, toileting and repositioning according to their care plan.
Lake Andes Senior Living: The 43-bed for-profit facility in Lake Andes is affiliated with Accura Healthcare. The home has been cited 18 times since the start of 2024 and was fined $91,601 in the last three years. It has been a special focus candidate for six months.
The home was flagged for “immediate jeopardy” to patient health in two citations in the September report, including not notifying four diabetic residents’ doctors when their blood sugar levels veered outside a normal range and failing to manage and prevent a COVID outbreak among residents. The report does not provide details on the size or results of the outbreak.
It was also cited in a September complaint inspection when a resident left the facility without supervision. The facility reviewed its policy for missing residents, ran drills among staff and audited alerting technology used by the facility.
Wilmot Care Center: The 29-bed nonprofit nursing home has been cited 17 times since the beginning of 2024 and has paid $10,377 in the last three years. The facility has been a special-focus candidate for two months.
The facility was flagged for “immediate jeopardy” to residents in its February 2024 report and its March 2025 report both for quality of life and care deficiencies. In March, an inspector found a water leak from the facility’s whirlpool tub next to an electrical box, which increased the risk of electrical shock to residents and staff. In February last year, a resident left the facility without staff’s knowledge and was retrieved by a staff member about a half-mile away. Staff left the facility’s front door unlocked and the resident cut off their tracking and alert device before leaving the facility.
Good Samaritan Society Sioux Falls Center: The 98-bed nonprofit nursing home graduated from the special-focus program in July 2023, after spending over two years on the list. It was cited for four deficiencies since the beginning of 2024 and has been fined twice for a total of $38,301 in the last three years.
The home was found noncompliant during its last state inspection report in June last year for infection prevention and control, food storage and preparation, and using expired medications.
