Tekakwitha Living Center: Woodworking Injuries - SD
The woodworking accidents occurred repeatedly over eight months despite a safety plan that required staff supervision when the resident used power tools.
Federal inspectors found the facility failed to implement effective safety precautions for the resident, identified as Resident 10, who had been diagnosed with age-related cognitive decline and Alzheimer's disease. His cognitive test scores declined from 26 out of 30 in November 2023 to 10 out of 15 by July 2024, indicating moderate impairment.
The first injury occurred on October 22, 2023, when the resident came to nurses with his left pointer finger bleeding. "Resident stated he was working with his table saw and the piece of wood slipped and got his finger, tip of finger noted to be cut off," according to nursing notes. The severed fingertip was cleaned, treated with antibiotic ointment, and bandaged.
Following that incident, occupational therapists evaluated the resident's cognitive abilities and woodworking safety. The assessment noted he had been "performing woodworking tasks for years" but scored 26 out of 30 on a mental status exam, indicating mild neurocognitive disorder.
The facility developed a safety plan requiring the resident to wear non-skid shoes, use a walkie-talkie to communicate with staff, and ensure power switches were off before plugging in tools. Staff were instructed to check on him often.
But the accidents continued.
Three weeks later, on November 17, 2023, the resident appeared at the nurses' station with a bloody left arm after "running into a piece of wood downstairs." The next day, he returned with his left thumb bleeding after bumping it "on hood," requiring cleaning and daily dressing changes.
The facility added safety gloves to his care plan intervention list.
The most serious incident occurred March 16, 2024, when the resident called for help from the basement workshop. A medication aide found him with his left hand wrapped in a bloody paper towel. "Noted deep, jagged cuts to 2nd, 3rd and fourth fingers," nursing notes stated. He was transported to the emergency room and returned with 20 stitches.
After that accident, administrators purchased a new electric saw with an automatic shut-off safety feature and added a requirement that staff supervise him whenever he used the saw.
But supervision proved inconsistent.
"This does not happen all the time," Director of Nursing B told inspectors when asked about the supervision requirement. She acknowledged the resident "will use the saw unsupervised" and would become "agitated with staff as he liked to be independent."
On June 18, 2024, the resident suffered another injury when his saw "kicked the boards back at him and hit his abdomen a few times." Nurses documented large bruises measuring 10 inches by 5 inches on his left side and 5 inches by 3 inches on his right side, with a small gash in the middle of the right-side bruise.
When inspectors visited in July 2024, they found the resident working alone in his basement workshop. He told them he used his electric saw "maybe once a day" and acknowledged that "at times the staff was busy, and I don't always get someone" when operating the saw. He couldn't locate his required safety gloves.
Activity Director J confirmed she would receive calls from the resident when "he needed to cut a board on his electric saw," but supervision remained sporadic.
The facility's policy stated it would "ensure that the resident's environment will be free from accidents and hazards" and would provide "supervision and assistive devices to each resident." It required identifying, evaluating, and analyzing hazards, then implementing interventions and monitoring their effectiveness.
Yet inspectors found no follow-up assessments, incident analyses, or reviews of interventions after any of the woodworking accidents. When they requested incident reports related to the resident's woodworking injuries, administrators provided none by the end of the survey.
The basement workshop was equipped with a walkie-talkie system connecting to multiple staff members, including administrators, nurses, and maintenance workers. The resident also carried his personal cell phone. But there were no video cameras or alternative monitoring methods when staff weren't directly supervising him.
Administrator A acknowledged the resident was "only to be working in the workshop between 7:00 a.m. and 8:00 p.m." and confirmed that maintenance and laundry staff in the basement would check on him during the day. However, this informal monitoring system failed to prevent the repeated injuries.
The resident's cognitive decline appeared to worsen during his time at the facility. His initial occupational therapy evaluation in November 2023 found him "alert and oriented x 4" and noted he "did assist with making a safety plan for all his woodworking tasks." But by July 2024, his cognitive test score had dropped significantly.
Social Service Designee C described the resident as "forgetful at times" but maintained he was "very aware of what he was doing." She noted his family was "very supportive of his woodworking" activities.
The facility also cited pressure ulcer prevention failures for another resident and problems with expired medications, food storage, and infection control procedures during the same inspection.
Director of Nursing B had been serving as the facility's infection preventionist for two years without proper training or certification. "She had not signed off as an IP because she had no training or certification as an IP," inspectors noted.
The woodworking injuries highlighted broader safety oversight failures at the 57-bed facility, where staff struggled to balance residents' independence with necessary precautions for those with cognitive impairments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tekakwitha Living Center from 2024-07-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
TEKAKWITHA LIVING CENTER in SISSETON, SD was cited for violations during a health inspection on July 18, 2024.
The woodworking accidents occurred repeatedly over eight months despite a safety plan that required staff supervision when the resident used power tools.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at TEKAKWITHA LIVING CENTER?
- The woodworking accidents occurred repeatedly over eight months despite a safety plan that required staff supervision when the resident used power tools.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SISSETON, SD, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from TEKAKWITHA LIVING CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 435038.
- Has this facility had violations before?
- To check TEKAKWITHA LIVING CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.