Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avera Morningside Heights Care Center during CMS and state inspections, most recent first.
A resident with advanced dementia, prior fractures, and high fall risk was informally placed on 1:1 supervision due to restlessness and constant movement in a wheelchair. While an NA was supervising the resident in a commons/dining area, the NA twice left the resident unattended and out of sight to assist with another resident and to wash hands and dispose of trash. During this time, the resident self-propelled away and sustained an unwitnessed fall, resulting in head lacerations and a displaced left olecranon fracture that later required surgery. Staff interviews confirmed they understood 1:1 to mean constant supervision, yet the resident’s care plan did not include a 1:1 intervention, and there was no clear facility policy defining 1:1 expectations.
QAPI failed to oversee the IP’s employee illness surveillance and failed to ensure employee health staff, who were not certified in infection control, were appropriately delegated to monitor staff illness. The IP relied on corporate EH to track illness and only received notice when a trend or outbreak was identified, with no daily documentation, no facility-specific employee illness data in QAPI, and no evidence that staff call-ins, return-to-work guidance, or correlation with resident illness were being reviewed. EH attended QAPI and discussed general illness trends and vaccinations, but the minutes did not show facility-specific staff surveillance, goals, or action plans.
Infection surveillance was incomplete because the IP tracked resident illness but did not maintain an ongoing system for staff illness. Nursing leadership described a process where staff absences were documented on communication forms and employee health handled return-to-work guidance, but the IP did not monitor whether ill staff actually contacted EH or whether return-to-work criteria were followed. Records showed inconsistent handling of ill nursing assistants, including one who worked despite diarrhea and another who left work with nausea and vomiting, with no clear documentation of return-to-work status.
The facility failed to ensure the IP had oversight of the IC program, including employee surveillance. Review showed only resident illness surveillance was completed, while staff illness was handled by corporate EH without a facility-level record. Interviews and records identified staff call-ins and illness episodes, including an employee who worked with diarrhea and another who left work with N/V, but the IP did not monitor whether staff contacted EH or consistently review staff illness data for QAPI. The DON agreed there was a lack of documentation and oversight related to staff illness.
A resident experienced an unwitnessed fall with significant facial injuries and was not promptly assessed or sent to the ER, despite developing worsening symptoms such as headache, nausea, vomiting, and hypoxia. Staff relied on telehealth provider recommendations and did not escalate care, partly due to the mistaken belief that a physician's order was required for ER transfer. Neurological checks were not completed per protocol, and family notification was delayed. The resident was eventually sent to the ER nine hours later, where severe brain injuries were diagnosed, and the resident died.
The facility failed to properly discard PPE and perform hand hygiene for a resident with C-Difficile, contrary to CDC guidelines. Staff also neglected Enhanced Barrier Precautions for a resident with a drug-resistant bacteria, and an LPN did not change gloves before administering eye ointment, breaching infection control practices.
During a meal service, a cook failed to follow infection control protocols, including not changing gloves or washing hands between tasks, and serving food with uncovered facial hair. The cook handled various items and food without proper hygiene, potentially affecting all residents on the unit. Interviews revealed a lack of awareness of infection control practices, despite existing policies requiring glove changes, handwashing, and hair restraints.
A resident with severe cognitive impairments and dependent on staff for all ADLs did not receive hand hygiene assistance before meals or during morning care routines. Despite being observed eating with her hands and touching potentially contaminated surfaces, staff did not perform hand hygiene as required by the facility's policy. Interviews confirmed that hand hygiene was typically done only after meals, contrary to expectations.
Failure to Provide Adequate Supervision for High Fall-Risk Resident on 1:1
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident at high risk for falls, resulting in a fall with major injury. The resident was admitted from the hospital with multiple fractures, including a right elbow fracture, was non–weight bearing to the right upper extremity, and had severe dementia with poor memory and severe aphasia. Assessments and the Falls CAA documented that the resident had a history of falls with fracture prior to admission, altered mental status, impaired mobility, and was considered at high risk for falls. Progress notes indicated the resident was described as "busy" but not behavioral, and identified risks including falls, pain, injury, and decline. On the day of the fall, documentation and staff interviews showed that the resident had been placed on one-to-one (1:1) supervision by nursing staff due to restlessness and safety concerns. The resident was being supervised in an open dining/commons area, self-propelling in a wheelchair while staff attempted to keep her under watch and provide snacks. The primary NA assigned to the resident reported that the resident had been under 1:1 supervision, moving around the unit in her wheelchair under observation. However, when another NA requested assistance with a two-person transfer for another resident, the supervising NA moved the resident near the other room, briefly left her unattended to assist with care behind a closed door, and then later left her again out of sight to dispose of trash and wash hands down the hall. During these periods, the resident was not under continuous observation despite staff acknowledging she was considered 1:1. During the time the resident was left unsupervised, she self-propelled her wheelchair into the dining room and experienced an unwitnessed fall. She was found on the floor in the middle of the room with her wheelchair behind her, having sustained head lacerations and an injury to her left elbow. The Fall Scene Investigation and follow-up documentation identified that the resident had hit her head and that the fall resulted in a displaced left olecranon fracture, later confirmed in the ED and requiring surgical intervention. The root cause section of the fall investigation noted that the resident was not on 1:1 at the time of the fall and that she had self-propelled and attempted to get up, leading to the fall. Staff interviews confirmed that they understood 1:1 to mean constant supervision and that leaving the resident alone, out of sight, occurred despite this understanding. The care plan, however, did not contain any intervention for 1:1 supervision, and facility leadership acknowledged there was no specific policy defining 1:1 expectations and differing interpretations existed regarding whether the resident required direct constant supervision versus frequent checks.
QAPI Failed to Oversee Infection Control Surveillance and Employee Illness Monitoring
Penalty
Summary
The facility failed to ensure its QAPI program provided oversight of the infection preventionist’s employee illness surveillance and failed to ensure employee surveillance was appropriately delegated to personnel in employee health who were not certified in infection control. The report states the facility used corporate employee health to track employee illness, but the infection preventionist had no oversight of that process, did not keep a record of employee illness, and relied on employee health to notify her only when a trend or outbreak was identified. There was no documentation that the infection preventionist was made aware daily of staff call-ins, that she reviewed employee illness data, or that she used employee illness information to correlate with resident illness or to verify staff return-to-work status. Interviews showed employees called corporate employee health when ill, where an RN completed an intake questionnaire and gave return-to-work guidance based on CDC and/or MDH recommendations. The infection preventionist stated she did not monitor whether staff actually contacted employee health when ill, did not oversee staff illness as part of her surveillance, and only discussed staff illness in QAPI if employee health reported an outbreak or other concern. The director of employee health stated the department was to notify the infection preventionist if a trend or pattern was noted, but there was no ongoing, current method of communication for illness that was not identified as a pattern or trend. Employee health staff were not certified infection preventionists, although the department had an infectious disease physician overseeing the program. Review of QAPI minutes from January through November 2025 showed the infection preventionist reported overall resident illness information, but no employee illness data was included in her reports. Employee health attended QAPI and made general comments about COVID, RSV, norovirus, influenza, measles, and employee vaccinations, but the minutes did not show facility-specific employee illness data, goals, action plans, or evidence that staff illness surveillance was being monitored. The quality assurance coordinator and DON both acknowledged there was a lack of documentation and oversight related to staff illness, and the system quality plan did not address infection control surveillance, QAPI oversight of the infection control program, data analysis, or delegation and oversight of employee health’s monitoring of staff illness.
Infection Surveillance Did Not Include Staff Illness
Penalty
Summary
The facility failed to maintain a current, ongoing infection prevention and control surveillance system that included staff illness. Review of infection control surveillance showed only resident illness surveillance had been completed at the facility. The infection preventionist stated that employee health handled staff illness tracking, while she was responsible for resident surveillance, and she did not keep a record of employee illness or receive a spreadsheet documenting staff symptoms and return-to-work dates. Interviews with nursing leadership and staff showed that when employees called in ill, charge nurses completed communication forms, notified managers, and sometimes directed staff to contact employee health. The director of nursing, unit supervisor, and licensed practical nurse described a process in which staff absences were documented on communication forms and filed, but the infection preventionist did not monitor whether staff actually contacted employee health. The infection preventionist stated she relied on department managers and employee health to ensure staff illnesses were followed, and she only discussed staff illness at QAPI if employee health reported an outbreak or trend. Review of staff illness records showed inconsistent documentation and follow-through. One nursing assistant reported multiple symptoms to employee health and was given a return-to-work date, but the criteria used were unclear. Another nursing assistant had diarrhea documented on the communication form, yet time punches showed she worked her shift and the next day, with no documentation that she was prohibited from working or that employee health was contacted. A third nursing assistant left work with nausea and vomiting, but there was no indication of when she was allowed to return. Employee health also reported that it did not have an ongoing current method of communication with the facility for illnesses that were not identified as a pattern or trend, and the director of nursing acknowledged there was a lack of documentation and oversight related to staff illness.
Infection Preventionist Lacked Oversight of Employee Illness Surveillance
Penalty
Summary
The facility failed to ensure the infection preventionist had appropriate oversight of the infection control program, including employee surveillance of all employees. Review of the facility’s infection control surveillance showed that only resident illness surveillance had been completed, and employee surveillance had not been included. The infection preventionist stated that employee illness was handled by corporate employee health and that she did not keep a record of employee illness at the facility. She also stated she was responsible for resident surveillance, while employee health tracked employee illness for the facility. Interview and record review showed that staff illness information was not consistently documented or monitored at the facility level. A communication form and time punches identified a nursing assistant who called in ill, another nursing assistant who worked while reporting diarrhea, and a third nursing assistant who left work with nausea and vomiting. For one employee, employee health documentation showed symptoms of cough, sore throat, fatigue, diarrhea, and vomiting, with a return-to-work determination noted by employee health. For another employee, there was no documentation that the illness had been reported to employee health. For the third employee, employee health documented symptoms including shortness of breath, headache, sore throat, runny nose/congestion, fatigue, and muscle aches, with guidance about returning to work after symptom improvement and being fever free. The infection preventionist stated she did not monitor whether staff followed through with contacting employee health when ill and relied on management and employee health for that process. She also stated she only brought staff illness information to QAPI if employee health reported an outbreak or trend, and she had not brought routine staff illness information to QAPI. The director of nursing agreed there was a lack of documentation and oversight related to staff illness and confirmed the infection preventionist was responsible for oversight of the infection prevention program, including employee/staff surveillance. The infection prevention program policy stated the infection preventionist was to implement surveillance, analyze data, and oversee infection control measures, but a job description for the infection preventionist was not provided.
Failure to Timely Assess, Intervene, and Escalate Care After Resident Fall Resulting in Death
Penalty
Summary
The facility failed to ensure that staff appropriately assessed, monitored, intervened, and notified the family in a timely manner following a resident's unwitnessed fall, which resulted in a brain bleed, skull fracture, and eventual death. After the fall, the resident was found with visible facial bruising, swelling around the eyes, a bruised nose, and bleeding from the hand, but denied pain and hitting his head. Despite these injuries and the unwitnessed nature of the fall, staff did not immediately contact a physician or the resident's family, nor did they send the resident to the emergency room for evaluation. Instead, the resident was monitored in the facility, and only telehealth (E-Care) providers were consulted, who did not identify the need for urgent in-person evaluation. As the resident's condition deteriorated, including the onset of headache, nausea, vomiting, elevated blood pressure, and hypoxia, staff continued to follow telehealth provider recommendations, which included administering medications and ordering diagnostic tests, but did not escalate care to an emergency room visit. The nurse on duty believed she required a physician's order to send the resident to the ER and did not act on her own clinical judgment, despite concerns voiced by other staff members. Neurological checks were not performed according to protocol, and there was a lack of clear communication and escalation through the chain of command, even as the resident's symptoms worsened. The resident was not transferred to the emergency room until approximately nine hours after the fall, when the primary care provider arrived and recognized the severity of the situation. At the hospital, the resident was diagnosed with multiple skull fractures, brain bleeds, and herniation, and subsequently died. The facility's policies required immediate assessment, notification, and escalation for head injuries or changes in condition, but these were not followed. Staff interviews revealed confusion about the need for a physician's order to send a resident to the ER and a lack of empowerment to act on clinical judgment in emergent situations.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to properly discard personal protective equipment (PPE) and perform appropriate hand hygiene for a resident with Clostridium Difficile (C-Difficile). A nursing assistant was observed removing gloves and gown in the hallway outside the resident's room and disposing of them in a waste bin without washing hands with soap and water, as required for C-Difficile cases. Instead, the assistant used alcohol-based hand rub, which is ineffective against C-Difficile spores. This practice was contrary to the facility's policy and the CDC guidelines, which emphasize the importance of using soap and water for hand hygiene after caring for residents with C-Difficile. Another deficiency was noted in the facility's failure to adhere to Enhanced Barrier Precautions (EBP) for a resident with an open scalp wound due to a drug-resistant bacteria. Staff members entered the resident's room wearing gloves but no gowns, despite the posted precautions requiring both for high-contact activities such as transferring and changing briefs. The staff acknowledged forgetting to wear gowns, which was a breach of the facility's policy and the posted EBP requirements. Additionally, during a medication pass observation, a licensed practical nurse (LPN) failed to change gloves and perform hand hygiene before administering eye ointment to a resident. The LPN handled multiple surfaces with gloved hands before applying the ointment, which was against the expected infection control practices. The director of nursing confirmed that clean gloves should have been donned just prior to administering the eye ointment, highlighting a lapse in following proper procedures.
Infection Control Lapses During Meal Service
Penalty
Summary
The facility failed to ensure appropriate infection control techniques during a meal service on the Gardens unit, potentially affecting all 20 residents. Observations during the supper meal revealed that cook-A engaged in multiple incidents of potential cross-contamination and did not adhere to proper hand hygiene protocols. Cook-A was seen serving food with facial hair uncovered and wearing the same gloves while handling various items, including opening cabinets, refrigerators, and freezers, and then returning to serve food without changing gloves or washing hands. Throughout the meal service, cook-A continued to use the same gloves while performing different tasks, such as handling food, touching surfaces, and writing notes, without any glove changes or hand hygiene. Cook-A also wore a braided bracelet uncovered by gloves while serving food, further increasing the risk of contamination. Additionally, cook-A handled a bowl with a black mark, identified as ink, without changing gloves or washing hands before continuing to serve food. Interviews with cook-A and the dietary manager revealed a lack of awareness and adherence to infection control practices. Cook-A admitted to not realizing the need for glove changes and hand hygiene between tasks, despite having received education on infection control. The dietary manager confirmed the expectation for staff to change gloves and perform hand hygiene when switching between food handling and other tasks, but was unaware of the requirement to cover facial hair. The facility's food safety and sanitation policy mandates glove changes and handwashing after touching contaminated surfaces and requires hair restraints during food preparation and service.
Failure to Provide Hand Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure proper hand hygiene for a resident, identified as R21, who was dependent on staff for all activities of daily living (ADLs) and had severe cognitive impairments due to Alzheimer's disease and dementia. Observations revealed that R21 did not receive hand hygiene assistance before meals or during morning care routines. Despite being dependent on staff, R21 was observed eating with her hands without any hand hygiene being performed, even after touching potentially contaminated surfaces such as a recliner, wheelchair, and dining table. Interviews with staff confirmed that hand hygiene was not consistently provided to R21 before meals, contrary to the facility's hand hygiene policy. R21's care plan indicated she required assistance with eating and was not provided with silverware, leading her to eat with her hands. Observations showed that R21's fingernails were long and had dark debris underneath, raising concerns about cleanliness. Staff interviews revealed that hand hygiene was typically performed only after meals, not before, which was against the nurse supervisor's expectations and the facility's hand hygiene policy. This lack of adherence to proper hand hygiene protocols for a resident who is unable to perform self-care tasks represents a deficiency in the facility's care practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marshall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie View Senior Living | 17.1 mi | ★★★★★ | 6 | 0 |
| Avera Sunrise Manor | 21.3 mi | ★★★★★ | 0 | 0 |
| Clarkfield Care Center | 23.9 mi | ★★★★★ | 5 | 0 |
| Wabasso Restorative Care Center | 26 mi | ★★★★★ | 23 | 0 |
| Parkview Home | 27.8 mi | ★★★★★ | 8 | 0 |
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