Medicine Wheel Village
24266 Airport Road · Eagle Butte, SD · 57625 · 6059648155
50 certified beds Non profit - Other
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- Staffing hours comfortably above national benchmarks.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 4.06 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.69 | 0.55–0.75 |
| Weekend hours / resident-day | 3.50 | ≈ weekday level |
| Nursing turnover / year | 23% | median 45% |
| Fines (3-yr window) | 1 · $22,636 |
Inspection citations (27 in the current record)
-
Potential for harm · D March 25, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Past Non-Compliance · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D March 25, 2026 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Past Non-Compliance · Resident Assessment and Care Planning
-
Immediate jeopardy · L November 20, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 26, 2025 · Nutrition and Dietary
-
Potential for harm · D November 20, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 26, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D November 20, 2025
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected December 26, 2025 · Resident Rights
-
Potential for harm · D November 20, 2025
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected December 26, 2025 · Resident Assessment and Care Planning
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Potential for harm · E November 20, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected December 26, 2025 · Resident Assessment and Care Planning
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Potential for harm · D November 20, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected December 26, 2025 · Resident Assessment and Care Planning
-
Potential for harm · E November 20, 2025
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected December 31, 2025 · Quality of Life and Care
-
Potential for harm · F November 20, 2025
Post nurse staffing information every day.
Corrected December 26, 2025 · Nursing and Physician Services
-
Potential for harm · E November 20, 2025
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected December 26, 2025 · Pharmacy Service
-
Potential for harm · D November 20, 2025
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected December 31, 2025 · Nutrition and Dietary
-
Potential for harm · F November 20, 2025
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected December 26, 2025 · Nutrition and Dietary
-
Potential for harm · D November 20, 2025
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected December 26, 2025 · Administration
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Potential for harm · E November 20, 2025
Provide and implement an infection prevention and control program.
Corrected December 26, 2025 · Infection Control
-
Potential for harm · D November 20, 2025
Implement a program that monitors antibiotic use.
Corrected December 26, 2025 · Infection Control
-
Potential for harm · D October 3, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected November 2, 2024 · Resident Rights
-
Potential for harm · D October 3, 2024
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected November 2, 2024 · Pharmacy Service
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Potential for harm · F October 3, 2024
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected November 2, 2024 · Nutrition and Dietary
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Potential for harm · E October 3, 2024
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected November 2, 2024 · Nutrition and Dietary
-
Potential for harm · D October 3, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 2, 2024 · Nutrition and Dietary
-
Potential for harm · F October 3, 2024
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected November 2, 2024 · Administration
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Potential for harm · E October 3, 2024
Provide and implement an infection prevention and control program.
Corrected November 2, 2024 · Infection Control
-
Potential for harm · E October 3, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected November 2, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D August 3, 2023
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected September 20, 2023 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| November 20, 2025 | Fine | $22,636 |
Better-scoring options nearby
No better-scoring facility within 25 miles in the current data. See the whole state.
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 43A138 · certified since February 5, 2019. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.