Dow Rummel Village: Resident Safety Violations - SD
The October incident at Dow Rummel Village involved a resident who required assistance with transfers. Staff used a sit-to-stand mechanical lift on the woman, but the facility's own April 2024 Safe Patient Handling policy specifically states that residents using stand aide lifts "must be able to provide weight bearing assistance through all extremities."
The policy warns that if a resident is found "hanging or chicken winging" in the stand aide lift, staff must switch to a Hoyer lift for both resident and healthcare provider safety.
Federal inspectors found the resident developed a laceration on her right lower leg that required daily dressing changes until healed, as ordered by her physician. During an inspection observation on October 30, the resident showed no signs of pain during her wound care, but the injury necessitated ongoing medical treatment.
RN C, who was involved in the transfer, told inspectors she was not aware the resident was more agitated on October 3 than she normally was. The resident's increased agitation may have been an indicator that the transfer method was inappropriate for her condition.
The facility's policy requires nursing staff to consult leadership or skilled therapy for guidance when uncertain about safe transfer methods. Nursing staff can independently decide to downgrade a transfer method to a safer option, but any upgrades must involve physical therapy and occupational therapy.
Healthcare providers are required to follow resident care plans for proper and safe transfers. The facility maintains electronic medical records that certified nursing assistants can access to find individualized care plans detailing what assistance each resident requires.
RN and Minimum Data Set coordinator E explained that pocket care plans were supposed to be updated daily by herself and nursing staff. These plans help ensure staff know the appropriate level of assistance and equipment needed for each resident's transfers.
The inspection revealed gaps between the facility's written policies and actual practice. While Dow Rummel Village had comprehensive safety protocols for patient handling and mobility, staff failed to follow the specific requirements for residents who cannot bear weight through their extremities.
The resident's injury occurred despite clear policy guidance about when to use different types of lifting equipment. The facility's own rules state that residents must be able to provide weight bearing assistance through all extremities to safely use a stand aide lift.
When residents cannot meet this requirement, staff are directed to use a Hoyer lift instead. This type of lift provides full body support and eliminates the risk of residents hanging or struggling during transfers.
The violation resulted in actual harm to the resident, requiring ongoing medical treatment and daily wound care. Federal inspectors classified the incident as affecting few residents but causing measurable harm.
Dow Rummel Village's comprehensive patient handling policy demonstrates the facility understood the safety requirements for different types of mechanical lifts. The policy specifically addresses the risks of using inappropriate equipment and provides clear guidelines for when to upgrade or downgrade transfer methods.
The resident's leg laceration serves as a concrete example of what can happen when staff don't follow established safety protocols. Her daily dressing changes represent the ongoing consequence of a transfer that should have been performed with different equipment according to the facility's own standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dow Rummel Village from 2025-10-30 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 20, 2026 · Our methodology
DOW RUMMEL VILLAGE in SIOUX FALLS, SD was cited for violations during a health inspection on October 30, 2025.
The October incident at Dow Rummel Village involved a resident who required assistance with transfers.
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.