1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Lake Norden, SD
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
803 Park Street, Lake Norden, SD
(605) 785-3654
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
48
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1991-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.78
Registered nurse staffing
LPN hours / resident day
0.33
Licensed practical nurse staffing
Aide hours / resident day
2.11
Nurse aide staffing
Weekend hours
2.84
Weekend nurse staffing
RN turnover
30%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.9
1.6 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
95.4%
4 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
96.9%
0.7 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
5.1%
1.5 pts better
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 11.4% |
4.6%
6.8 pts worse
|
11.4%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.0% |
5.5%
3.5 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.6% |
17.8%
8.8 pts worse
|
19.6%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 19.7% |
25.1%
5.4 pts better
|
16.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.7% |
21.3%
3.4 pts worse
|
16.3%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.0% |
21.6%
7.4 pts worse
|
14.9%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
2.0%
0.1 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
3.3%
2.7 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.3% |
25.8%
5.5 pts worse
|
19.8%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.6%
2 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
83.2%
13.6 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.4% |
11.7%
3.3 pts better
|
12.0%
3.6 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.7%
1.7 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
78.2%
18.8 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.7% |
21.5%
11.8 pts better
|
23.9%
14.2 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Resident Assessment and Care Planning (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-18
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-30
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-12-31
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-06
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-03
Fire Safety
Have an externally vented heating system.
Corrected 2023-01-19
Inspection history
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-25
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-28
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-28
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-14
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
5% Or Greater Security Interest · Organization
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