Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Brady Health And Rehab during CMS and state inspections, most recent first.
Failure to Maintain Hand Hygiene During Meal Prep: During lunch service, a cook dropped a butter container lid on the floor, picked it up, and continued plating food without hand hygiene. She also coughed into her hand while holding a resident plate, drank from her personal cup placed on a food transport cart, and kept preparing resident meals without washing or sanitizing her hands. The ADM and DM gave conflicting views on the beverage placement, but the DM stated the cart top was not a designated space for staff drinks.
A resident with intact cognition, obesity, depression, anxiety, chronic pain, constipation, fibromyalgia, overactive bladder, and bowel/bladder incontinence was left on a commode after her call cord did not activate and staff did not return to check on her. The resident had to yell for help, was found upset after waiting longer than she wanted, and the facility’s orange magnet process for indicating a resident was on the toilet/commode was not followed. The incident was identified as neglect, and the facility also did not assess other residents’ call cords for proper function.
A resident with Parkinson’s disease, a history of falls, and intact cognition routinely used a whirlpool tub chair without the safety belt, despite manufacturer instructions that all users must be securely belted and facility education stating all residents are to use the strap unless refusal is care planned. The resident’s care plan noted she may or may not use the belt, but her record lacked documentation that she was assessed as not requiring it or that she was educated on the risks and potential adverse outcomes of not using it. The resident reported she was not really aware she could fall by not using the belt, while staff indicated all other residents used the safety belt unless otherwise care planned, and leadership acknowledged there was no documentation of the claimed safety education.
The facility failed to provide a written summary of the baseline care plan to several residents within 48 hours of admission, as required by policy. This deficiency was identified through record reviews and interviews, revealing that some residents, including those with severe cognitive impairments and significant medical conditions, did not receive their care plans until days or weeks after admission. The facility's misunderstanding of the regulation and delayed communication contributed to this issue.
Two residents experienced significant delays in call light response, with wait times often exceeding 30 minutes, leading to incontinence and unmet assistance needs. Both residents were cognitively intact and had their call lights within reach. The facility's policy aimed for a 10-minute response time, but this goal was not consistently met, as confirmed by the DON.
A resident was allowed to self-administer a nebulizer treatment without a self-administration medication order. An RN set up the treatment and left the room, failing to monitor the resident. The resident's EMR lacked the necessary self-administration order and evaluation. The DON confirmed that such orders are required for self-administration, and the facility's policy mandates an interdisciplinary team assessment and physician's order, which were not completed.
Failure to Maintain Hand Hygiene During Meal Preparation
Penalty
Summary
Food safety practices were not followed during lunch meal service when cook I dropped the lid to a butter container onto the floor, picked it up, and placed it on the counter next to an open bag of bagels without performing hand hygiene. She then prepared a plate of food for a resident and, while holding the plate in her left hand, coughed into her right hand. After coughing, she continued preparing additional plates of food for residents without washing or sanitizing her hands. Hand sanitizer was available on the counter next to the steam table line and on the north wall of the dining room. During the same meal service, cook I had her personal beverage cup sitting on top of the food transport cart located in the kitchenette next to the serving line. She took a drink from the cup, placed it back on the cart, and continued preparing resident plates without performing hand hygiene. The assistant dietary manager stated the cup location was appropriate, while the dietary manager stated the top of the food transport cart was not a designated space for staff beverages and expected staff to follow the handwashing policy. Cook I acknowledged she should have set the plate down and washed her hands after coughing into her right hand and should have started over with a clean plate.
Failure to Ensure Toileting Checks and Working Call System Cord
Penalty
Summary
The facility failed to provide appropriate toileting assistance and functioning call system access for a resident who required two staff members and a sit-to-stand lift for toileting. Resident 41 had morbid obesity, depression, anxiety, chronic pain, constipation, fibromyalgia, overactive bladder, bowel and bladder incontinence, and a BIMS score of 13 indicating intact cognition. Her care plan stated she used a bedside commode, wanted to be toileted at 4 a.m., used her call light the rest of the time, and needed frequent checks when her door was closed. On 3/5/26, Resident 41 was found sitting on the commode after yelling for help. She stated she had been waiting for someone to answer her call light and had tried to call for help at 4:45 p.m. The RN tested the call light and found it would not activate until the cord was unplugged and replugged. Maintenance later replaced the call system cord and adjusted the placement of the call system box and cord. The facility’s investigation determined that Resident 41 had been on the commode about 30 minutes longer than she wanted to be. The report also states CNA N did not return to the resident’s room to check on her, and the orange magnet process used to indicate a resident was on the toilet or commode was not followed. Administrator A stated Resident 41 was distressed, upset, and had tears in her eyes when discussing the incident. The facility’s policy defined neglect as failing to provide goods or services a resident requires when the facility is aware of, or should have been aware of, the need, and Administrator A acknowledged the incident met that definition. The report further noted that the facility did not assess other residents’ call system cords to ensure they were functioning.
Failure to Educate Resident on Risks of Not Using Whirlpool Chair Safety Belt
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision related to use of a whirlpool tub chair safety belt. The facility had prior South Dakota Department of Health facility-reported incidents in which two residents fell when staff did not correctly use an assistive or safety device, including a whirlpool chair safety strap. The provider’s own Bath Chair Safety education stated that all residents are to use the bath chair strap unless the care plan reflects a refusal, and the whirlpool tub manufacturer’s manual required that all residents must always be securely safety belted at the waist when using the lift systems, warning that failure to secure the resident properly could result in injury. The resident at issue was admitted with diagnoses including Parkinson’s disease, diabetes, osteoarthritis, degenerative joint disease of the neck, and a history of an L2 compression fracture and falls. Her care plan documented that she was offered the whirlpool tub chair safety belt but may or may not use it, and she had hand tremors. Her BIMS score of 14 indicated intact cognition. There was no documentation in the electronic medical record that she had been assessed as not requiring the safety belt, and no documentation that she had been educated on the risks and potential adverse outcomes of not using the whirlpool safety belt. Staff interviews and observations showed that, in practice, all residents used the whirlpool chair safety belt except this resident. A CNA reported that all residents wore the safety belt unless the care plan indicated it was not required. The resident stated she used the whirlpool tub chair without the safety belt and reported she was not really aware that she could fall by not using it. The DON and administrator stated that the resident chose not to wear the safety belt and that this decision was reflected in her care plan, and the DON reported she had provided education about safe use of the safety belt, but there was no documentation of this education in the resident’s record, despite the manufacturer’s instructions that all residents must always be securely belted when using the whirlpool chair.
Failure to Provide Timely Baseline Care Plans
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to five of eighteen sampled residents within 48 hours of their admission. This deficiency was identified through a review of electronic medical records, interviews, and policy reviews. For instance, one resident with severe cognitive impairment due to a stroke did not receive a baseline care plan until the fourth day of her stay. Another resident, who was cognitively intact, did not receive her baseline care plan until the twenty-fifth day of her stay, and the facility was unable to provide a printed copy as the resident had been discharged. The facility's policy required that a baseline care plan be developed within 48 hours of admission to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events. However, interviews with the director of social services and the administrator revealed that the facility did not consistently provide the baseline care plan summary to residents or their families within the required timeframe. The director of social services admitted to waiting three to four days after admission before providing the baseline care plan, which was contrary to the facility's policy. The deficiency was further highlighted by the facility's misunderstanding of the regulation regarding the timing of providing the baseline care plan summary. The administrator and director of nursing acknowledged that they had not provided all residents and/or families with the summary within 48 hours of admission. This lack of timely communication and documentation was evident in the cases of several residents, including those with significant medical conditions such as congestive heart failure, pneumonia, and diabetes mellitus, who did not receive their baseline care plans promptly.
Delayed Call Light Response for Two Residents
Penalty
Summary
The provider failed to maintain the physical, mental, and psychosocial well-being of residents by not ensuring prompt response to call lights for two residents. Resident 1 reported that it sometimes took staff 30-60 minutes to respond to her call light, resulting in incontinence of bowel and bladder due to the delay. Resident 16 also experienced significant delays, stating that staff blamed the call light system for the slow response, and she had waited over an hour on some occasions. Both residents had their call lights within reach and were cognitively intact, as indicated by their BIMS scores of 15. Call light audit reports for both residents showed numerous instances of response times exceeding 10, 20, and even 30 minutes, with the longest wait times being 72 minutes and 68 minutes for residents 1 and 16, respectively. The facility's policy aimed for a response time within 10 minutes 87% of the time, but this goal was not met. The director of nursing acknowledged that a 30-minute wait was excessively long and confirmed that all staff were responsible for answering call lights. Monthly audits were being conducted, but the delays persisted, indicating a failure to adhere to the facility's call light policy.
Failure to Monitor Nebulizer Treatment
Penalty
Summary
The provider failed to correctly administer medication to a resident by allowing her to self-administer a nebulizer treatment without a self-administration medication order. During an observation, a registered nurse (RN) set up the albuterol/ipratropium nebulizer treatment for the resident and handed her the nebulizer tube. The RN paused the treatment when the resident was on the phone and resumed it afterward, leaving the room without monitoring the resident during the treatment. Upon review, it was found that the resident did not have a self-administration medication order or evaluation documented in her electronic medical record (EMR), which was required before allowing self-administration. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had been admitted with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease. The director of nursing confirmed that residents must have a self-administration medication order to self-administer medications and agreed that the RN should have monitored the nebulizer treatment. The facility's policy required an interdisciplinary team assessment and a physician's order for self-administration, which were not completed for this resident.
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Illustrative
What surveyors actually found near you
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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 Mitchell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Firesteel Healthcare Center | 2 mi | ★★★★★ | 6 | 0 |
| Avera Bormann Manor | 21.5 mi | ★★★★★ | 9 | 0 |
| Good Samaritan Society Corsica | 26.4 mi | — | 0 | 0 |
| Prairie View Healthcare Center | 26.5 mi | ★★★★★ | 2 | 0 |
| Diamond Care Center | 29.2 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.