Kadoka Nursing Home: Elopement Care Plan Failures - SD
That gap was still there when inspectors arrived two months later.
The resident, identified in inspection records only as Resident 1, had a pattern of behavior that nearly every staff member at the facility knew by heart. A laundry worker who had been there three years knew she sometimes forgot her walker and drifted toward the front door. A nursing assistant with four years at the facility knew she packed a bag to go home because she believed she had a baby boy waiting for her. Staff had learned to meet her at the entrance, offer reassurance that the boy was fine, call a family member to talk her down, or get her daughter on the phone. They knew her confusion spiked in the late afternoon, a pattern called sundowning. They knew outings with her daughter sometimes left her more agitated when she returned. They knew a urinary tract infection made everything worse.
They knew all of it. None of it was in her care plan.
The MDS nurse responsible for completing resident assessments and updating care plans worked one day a week at the facility. When inspectors interviewed her on May 27, she acknowledged directly that Resident 1's care plan did not address wandering, exit-seeking, or elopement risk, even though she was aware the resident demonstrated all three behaviors. The administrator, the director of nursing, the assistant director of nursing, and the facility's social services director all acknowledged the same thing in a group interview that afternoon: the information should have been there, and they shared responsibility for making sure it was.
The facility's own elopement policy, revised on April 11, 2026, three weeks after the March incident, stated that following a resident elopement, the care plan should be updated with additional approaches. It hadn't been.
When inspectors observed Resident 1 on the afternoon of May 27, she was seated near the nurses' station, neatly dressed, smiling, her walker in front of her. Later, in the activity room, she approached the administrator and asked about going out to the rodeo. The administrator told her it was too hot outside and the rodeo might be over. The resident accepted that and mentioned she had been up working since 8 in the morning anyway.
The facility had taken some steps after the March elopement. All staff were briefed on how wandering and exit-seeking behaviors were expected to be managed. A mock elopement drill was conducted on April 28. Cameras monitored every entrance, and a television at the nurses' station displayed those feeds in real time. Every door would alarm if opened by anyone other than an employee. On the night Resident 1 left, the alarm worked, staff responded as trained, and the resident was located.
The administrator offered context for what happened that March night: high winds may have woken her, the UTI likely deepened her confusion, and the combination pushed her out the door. That may be true. But the inspectors' finding was not about the night itself. It was about the two months that followed, during which the people responsible for her care plan, five of them named in the inspection report, did not update it to reflect what they all already knew.
The interventions that staff had developed through trial and experience were real and apparently effective. Verbal redirection. Family calls. Anticipating hunger, thirst, continence needs before the resident grew agitated. Limiting off-grounds outings when she seemed unsettled. Individualized activities to keep her engaged. A woman who believed she had a baby at home and needed to get back to him had been met, again and again, with patience and creativity by the people who cared for her.
Those interventions just weren't written down anywhere that the next shift, the next aide, or the next nurse coming in for the first time would ever find them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kadoka Nursing Home from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 12, 2026 · Our methodology
Kadoka Nursing Home in KADOKA, SD was cited for violations during a health inspection on May 27, 2026.
That gap was still there when inspectors arrived two months later.
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.