Black Hills Surgical Hospital LLC
An acute care hospital in Rapid City, South Dakota 57703
216 Anamaria Dr, Rapid City, South Dakota 57703. (605) 721-4700.
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The short answer
Record last released by CMS on Oct 20, 2026.
- Not rated CMS’s overall rating
- 5of 5 patient survey rating
- 1 deficiency cited in the last three years
- 26 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Jun 17, 2026: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited Jun 2026. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
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| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Jun 17, 2026: complaint inspection1 deficiency
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Maintenance Of Physical Plant
The inspectors’ words, 888 words
“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 50715 Based on observation, interview, infection prevention rounding report review, policy review and Administrative Rules of South Dakota review, the provider failed to ensure that three of twelve observed operating room (OR) floors (3, 4, and 5) and adjacent OR hallway flooring surfaces were maintained as smooth, nonporous, and cleanable surfaces to prevent the potential for the growth and transmission of pathogenic organisms. Findings include: 1. Observation on 6/16/26 at 3:30 p.m. of ORs 3 and 5 revealed multiple defects in the flooring system, including uneven floor surfaces, divots, gouges, and coved (curves up the wall a few inches instead of ending where the floor meets the wall) bases that were not integral with the floor and contained visible voids and gaps. These defects prevented effective cleaning and disinfection of the surfaces and created areas where dust, debris, moisture, and potentially harmful microorganisms could accumulate and harbor bacteria. Areas of clear sealant were applied to portions of the flooring; however, the sealant had deteriorated and contained visible accumulations of dirt and debris. The flooring defects prevented the surfaces from being maintained as smooth and readily cleanable and created areas where dust, debris, and moisture could accumulate. 2. Interview on 6/16/26 at 3:52 p.m. with the director of surgery F confirmed the above findings. She stated the maintenance staff had performed repairs to the exposed areas as needed; however, those repairs did not provide a long-term solution. She further stated the OR floors would ultimately require replacement to support effective cleaning and disinfection. 3. Interview on 6/17/26 at 8:45 a.m. with chief executive officer (CEO) A, chief operating officer (COO) C, and chief nursing officer (CNO) B revealed leadership were aware of the compromised condition of the OR flooring and had monitored the issue. Leadership stated that the replacement of the OR flooring was included in the capital budget discussions; however, the project was not approved. 4. Observation on 6/17/26 at 10:30 a.m. in OR 4 identified multiple divots and gouges in the center and perimeter areas of the room. The coved bases were separating from the wall and floor surfaces, and portions of the flooring material were loose. Dirt and debris were observed within the divots, gaps, and uneven flooring surfaces. 5. Observation on 6/17/26 at 10:45 a.m. of the surgical hallway surrounding ORs 3, 4, 5, and 6 identified similar flooring defects, including divots, gouges, uneven flooring surfaces, and deteriorated flooring material. 6. Interview on 6/17/26 at 10:50 a.m. with director of surgery F and clinical care leader G confirmed the above findings and stated that the condition of the flooring affected the ability to effectively clean and disinfect the surfaces. 7. Interview and review of the infection prevention (IP) rounding report on 6/17/26 at 12:30 p.m. with CNO B and director of quality E revealed that environmental rounds were conducted monthly on a rotating basis throughout the surgical hospital, with the OR areas evaluated twice annually. The OR area had last been assessed on 1/24/26 by IP staff. Findings were communicated to the department managers for corrective action and follow-up reporting. The 1/24/26 IP rounding report revealed holes, chips, visible cracks, and compromised flooring surfaces had been identified in ORs 1, 2, 8, and 9, as well as in the adjacent hallway. The report recommended repair or replacement of the flooring to restore smooth, intact, and cleanable surfaces consistent with infection prevention requirements. The flooring in ORs 3, 4, and 5 was not mentioned in the rounding report, but it was reported that throughout the OR, “Given the widespread and structural nature of the damaged surfaces, bringing the OR into compliance through routine maintenance alone would not be feasible, and that a comprehensive OR remodel should be done.” CNO B was aware of the flooring concerns throughout the OR but acknowledged a gap in the process for communicating and following up on major capital improvement items. The director of quality E confirmed that the integrity of the ORs and adjacent hallway flooring, and the ability to effectively clean and disinfect the surfaces was an ongoing concern. 8. During the observations, ORs 1, 2, 8, and 9 were unable to be observed due to OR surgical procedures. 9. Review of the provider’s 4/30/25 Operating Room Environmental Sanitation policy revealed the purpose was: “To provide guidelines for minimizing exposure to potentially infectious waste with the goal of providing a clean environment for both the surgical patient and the healthcare worker.” The floors were mopped with a hospital EPA (Environmental Protection Agency) registered disinfectant between surgical procedures, and at the end of the day, terminal cleaning was performed on the entire floor using mechanical friction with an EPA-registered disinfectant. “Multiple measures should be used to assess environmental cleaning practices (visual inspection of cleanliness, visual observation, and fluorescent marking).” 10. Review of the Administrative Rules of South Dakota 44:75:13:20 wall and ceiling finish revealed, “Wall bases in any areas used for surgical and obstetrical procedures shall be integral with either the wall or the floor surface material and shall be without voids that can harbor harmful bacteria.””
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jun 17, 2026 | Complaint inspection | 1 deficiency cited |
How do patients fare?
- CMS gives no overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “There are too few measures or measure groups reported to calculate a star rating or measure group score.”
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 1; safety of care, 1 better and 0 worse of 2; readmission, 2 better and 0 worse of 3.
- Patients rate it 5 of 5 in CMS’s patient survey (392 surveys completed, Oct 1, 2024 to Sep 30, 2025): 88% rated it 9 or 10 out of 10, and 88% would definitely recommend it.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): hip or knee replacement 3.8%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Medicare’s spending per patient here is 0.87 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | Not rated |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 5 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Feb 20, 1997.
- Ownership: proprietary.
- It is accredited by the Center for Improvement in Healthcare Quality (CIHQ), whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Proprietary.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 5 of 5.
- 81% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Sanford Health of South Dakota owns 100% directly since Nov 15, 2024.
- 26 owners or officers are people: Mark Allen Lundeen (corporate officer); Mark Allen Lundeen (corporate director); Marnie Lynn Ventling-Herrmann (corporate officer); Marnie Lynn Ventling-Herrmann (corporate director); Tony Lee Morrison (corporate officer); Tony Lee Morrison (managing employee (on the payroll)); Brent Gerard Teiken (corporate director); Dana James Dykhouse (corporate director); Andrew Stewart North (corporate officer); Andrew Stewart North (corporate director); Stephanie Marie Herseth Sandlin (corporate director); William Joseph Gassen (corporate officer); William Joseph Gassen (corporate director); George Joseph Brown (corporate director); Wesley Owen Engbrecht (corporate director); Tina Weston (managing employee (on the payroll)); Maureen Patricia Mccausland (corporate director); Thomas Richard Wenzel (corporate director); David Jonathan Shulkin (corporate director); Kyle Wiese (managing employee (on the payroll)); Neil Leslie Gulsvig (corporate director); Kevin Victor Schieffer (corporate director); Lauris Nelson Molbert (corporate officer); Lauris Nelson Molbert (corporate director); Nicholas Wayne Olson (corporate officer); Nicholas Wayne Olson (managing employee (on the payroll)).
- CMS’s Provider of Services file records 4 changes of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Sanford Health of South Dakota | Owns 5% or more directly | 100% | Nov 15, 2024 |
| Sanford | Owns 5% or more through other companies | 100% | Nov 15, 2024 |
How does it compare nearby?
- Of the 3 hospitals CMS lists in Pennington County, 1 has an overall star rating from CMS: 1 rated 3 of 5.
- CMS gives this hospital no overall star rating to compare.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Monument Health Rapid City Hospital | 3 |
| Same Day Surgery Center LLC | Not given |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
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Replies
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Paid listing
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