Wilmot Care Center INC
501 4th St, Wilmot, SD 57279 · Roberts County · 26 certified beds · avg 25 residents/day · certified since Apr 1, 2002
SFF Candidate
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, facility-wide · Mar 6, 2025 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Apr 2, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 29, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 28, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (18)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 6, 2025 | ▲ L · Immediate jeopardy, facility-wide | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 6, 2025 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Mar 6, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 6, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 6, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Nov 13, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Nov 13, 2024 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint |
| Jun 10, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Feb 29, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 29, 2024 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 29, 2024 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 29, 2024 | E · Potential for harm, repeated | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Mar 15, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (9 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | D |
| 2024 | 12 | 1 | J ▲ |
| 2025 | 5 | 1 | L ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $28,028.
| Date | Type | Amount / length |
|---|---|---|
| Mar 6, 2025 | Fine | $17,651 |
| Feb 29, 2024 | Fine | $10,377 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | South Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.25 | 4.32 | 3.95 | top 19% in South Dakota; top 10% in the U.S. |
| Registered Nurse hours | 1.12 | 0.91 | 0.69 | top 22% in South Dakota; top 11% in the U.S. |
| Weekend total nurse staffing | 4.66 | 3.71 | 3.50 | top 15% in South Dakota; top 10% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.74 | 0.51 | 0.48 | top 12% in South Dakota; top 14% in the U.S. |
| Total nursing staff turnover (%) | 60.5 | 48.2 | 45.8 | bottom 15% in South Dakota; bottom 16% in the U.S. |
| RN turnover (%) | 28.6 | 34.7 | 42.9 | top 43% in South Dakota; top 26% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.20, RN 0.90, weekend 3.72. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Beumer, Rachel | Individual | Corporate Director | NOT APPLICABLE | 10/18/2021 |
| Beumer, Rachel | Individual | Trustee of the SNF | NOT APPLICABLE | 10/18/2021 |
| Buttke, Leshea | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Buttke, Leshea | Individual | ADP of the SNF | NOT APPLICABLE | 02/11/2026 |
| Jurgens, Kevin | Individual | Corporate Director | NOT APPLICABLE | 10/01/2012 |
| Jurgens, Kevin | Individual | Trustee of the SNF | NOT APPLICABLE | 09/30/2021 |
| Pelzel, Heidi | Individual | Corporate Director | NOT APPLICABLE | 10/18/2021 |
| Pelzel, Heidi | Individual | Trustee of the SNF | NOT APPLICABLE | 09/30/2019 |
| Remund, Linda | Individual | Corporate Director | NOT APPLICABLE | 09/30/2022 |
| Remund, Linda | Individual | Trustee of the SNF | NOT APPLICABLE | 09/30/2022 |
| Van Beek, Jannette | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/02/2019 |
| Van Beek, Jannette | Individual | ADP of the SNF | NOT APPLICABLE | 04/18/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How do you handle residents who need modified food textures, and how do you make those meals appetizing?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Browns Valley Health Center | 12.7 mi | Browns Valley, MN | ★★★☆☆ | 2/5 | abuse |
| St William's Care Center | 17.3 mi | Milbank, SD | ★★☆☆☆ | 2/5 | |
| Avantara Milbank | 17.6 mi | Milbank, SD | ★☆☆☆☆ | 1/5 | |
| Tekakwitha Living Center | 19.9 mi | Sisseton, SD | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 435119.