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Complaint Investigation

Flandreau Santee Sioux Tribe Care Center

Inspection Date: September 30, 2025
Total Violations 1
Facility ID 43A139
Location FLANDREAU, SD
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Inspection Findings

F-Tag F0689

Quality of Life and Care Deficiencies
Harm Level: Actual Harm

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

that staff transport one resident at a time in their wheelchairs. She confirmed that she provided education to CNA D to utilize the walkie talkies to ask for help, and to transport one resident at a time rather than two at

a time. 16. Review of the provider's 1/22/23 FALLS-CLINICAL PROTOCOL policy revealed:* .3.

Documentation-Responsible Parties:--Nursing staff--Physicians (if required)*3.1. Incident Documentation-Fall Report: Document the details of the fall, including:--Date, time, and location of the fall.--Circumstances leading to the fall.--Observations of the resident's condition immediately after the fall.--Any witnessed reports or bystanders.--Interventions provided immediately after the fall.* .5. Post-Fall Evaluation and Prevention-Responsible Parties:-Nursing staff-Social Worker or Care Coordinator-Physical Therapists (if applicable)-Physician (if applicable)*5.1. Reassess Fall Risk-.Update Care Plan: Adjust the care plan to address fall prevention strategies, such as:--Increased supervision or assistance with mobility.*5.2. Family and Resident Education-Family and Resident Discussion: Educate the resident and their family about the fall and the potential consequences. Discuss preventative measures that can be implemented moving forward.-Environmental Modifications: Ensure the resident's environment is safe (e.g., removing tripping hazards, ensuring good lighting, and using non-slip rugs).*The policy did not include staff education to prevent falls.

Event ID:

Facility ID:

43A139

If continuation sheet

📋 Inspection Summary

FLANDREAU SANTEE SIOUX TRIBE CARE CENTER in FLANDREAU, SD inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FLANDREAU, SD, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FLANDREAU SANTEE SIOUX TRIBE CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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