Flandreau Santee Sioux Tribe Care Center: Safety Harm - SD
Federal inspectors responding to a complaint in September found that staff violated the facility's own safety procedures during wheelchair transport. The violation affected few residents but caused actual harm, according to the inspection report.
CNA D received education following the incident about utilizing walkie talkies to request assistance and transporting only one resident at a time rather than two simultaneously. The training came after the harmful incident had already occurred.
The facility's falls prevention policy, dated January 2023, outlined detailed documentation requirements for fall incidents. Staff must record the date, time and location of any fall, along with circumstances leading to the event and observations of the resident's condition immediately afterward.
The policy required nursing staff, physicians, social workers and physical therapists to conduct post-fall evaluations. These assessments must include reassessing fall risk and updating care plans with increased supervision or mobility assistance as needed.
Family and resident education formed another component of the protocol. Staff were supposed to discuss falls with residents and families, explaining potential consequences and preventative measures. Environmental modifications like removing tripping hazards and ensuring proper lighting were also mandated.
However, inspectors identified a critical gap in the facility's approach. The falls prevention policy contained no provisions for staff education to prevent falls from occurring in the first place.
The inspection revealed that proper protocols existed on paper but failed in practice. While the facility had comprehensive procedures for responding to falls after they happened, the lack of preventive staff training contributed to the harmful incident involving simultaneous wheelchair transport.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Flandreau Santee Sioux Tribe Care Center from 2025-09-30 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 9, 2026 · Our methodology
FLANDREAU SANTEE SIOUX TRIBE CARE CENTER in FLANDREAU, SD was cited for violations during a health inspection on September 30, 2025.
Federal inspectors responding to a complaint in September found that staff violated the facility's own safety procedures during wheelchair transport.
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.