Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avera Eureka Health Care Center during CMS and state inspections, most recent first.
Failure to Document Code Status Decisions and Advance Directives: The facility did not ensure EMR documentation supported the code status for multiple residents. Several residents had physician orders for DNR/DNI or full code, but their charts lacked completed code status forms and documentation showing the resident’s wishes were reviewed with the resident or representative. Some residents had severe cognitive impairment, one resident had intact cognition, and one resident’s Living Will and Durable Power of Attorney did not match the documented DNR/DNI status. The DON confirmed the missing documentation, and the facility policy required the physician to document the rationale and the risks, benefits, and choices discussed with the resident and family.
Bed-mounted assistive devices were used for multiple residents without consistent documentation of prior alternatives, physician orders, safety assessments, informed consent, or installation dates. Several residents had rails or assistive poles attached to their beds, including devices used for repositioning or transfers, and one rail was observed to move when shaken. Staff reported that a custom mount bracket had been made for the devices, while the DON stated she was unaware the devices were not compatible with the bed frames per the manufacturer manual. Facility policy required least restrictive methods first, physician orders, care plan review, and ongoing documentation, but those elements were not consistently present.
Rusty Walk-In Refrigerator Shelf Contaminated Raw Vegetables. A walk-in refrigerator had rust on metal wire shelves, and rust flakes were observed on the floor and on uncovered raw vegetables stored on the bottom shelf. The food service manager said he knew the shelves were rusting and that flakes could fall onto raw foods and potentially end up in residents' meals. The facility's food storage guidelines stated storage areas should be clean to prevent contamination and illness.
A resident with Dupuytren's contracture, anorexia, and other health issues experienced significant weight loss due to inadequate nutritional care. The facility failed to provide necessary adaptive silverware and consistent meal assistance, despite recommendations. Nutritional interventions were not effectively implemented, and there was confusion among staff about the resident's inclusion in the enhanced food program. Additionally, timely physician notification of weight changes was not ensured, contributing to the deficiency.
The facility failed to maintain proper food storage and sanitation practices, with items improperly stored under the food preparation sink, inadequate documentation for dishwasher sanitation, and inconsistent testing of sanitation levels. Staff did not follow proper food handling processes, and resident refrigerators were not consistently monitored for temperature, leading to expired food being found. The facility's policies on food safety and sanitation were not adhered to.
A LTC facility failed to follow infection prevention practices, including improper use of PPE for residents on enhanced barrier precautions, inadequate nebulizer tubing changes, and poor hand hygiene. Observations revealed unclean multi-use items in the beauty shop and tub room, and vital signs equipment was not disinfected between uses. Staff interviews confirmed gaps in training and adherence to facility policies.
The facility failed to properly store hazardous products and sharp objects in the beauty shop, leaving them accessible to residents. The beauty shop door was left open and unattended, with various products labeled as flammable or irritants stored in unsecured cupboards. A resident was observed looking into the open beauty shop before being redirected by staff. The DON was unsure who was responsible for maintaining the beauty shop's safety, and the facility's storage policy did not cover this area.
The facility failed to properly identify, reconcile, and secure scheduled controlled medications. Observations revealed a lack of reconciliation records for these medications, except for PRN controlled medications and Fentanyl patches. Interviews with staff, including the DON and consultant pharmacist, confirmed that scheduled controlled medications were not consistently tracked, and the EMR system did not automatically reconcile them. Nurses had to manually check medication bubble packs to identify residents receiving these medications, contrary to the facility's policy.
Failure to Document Resident Code Status Discussions and Advance Directives
Penalty
Summary
The facility failed to ensure code status was documented in the EMR for ten sampled residents, including residents with intact cognition, moderate impairment, and severe cognitive impairment. For residents 5, 8, 22, 12, 39, 40, and 45, physician orders indicated either DNR/DNI or full code status, but the EMRs did not contain completed code status forms or documentation showing that the residents’ wishes were reviewed with them or their representatives. Several of these residents had BIMS scores showing severe cognitive impairment, while resident 8 had a BIMS score of 15 indicating intact cognition. Resident 7’s EMR showed severe cognitive impairment and a physician order for DNR/DNI, but there was no advance directive paperwork completed on admission and no physician documentation supporting the code status order or showing discussion with the resident or representative. Resident 6’s EMR showed severe cognitive impairment and a DNR/DNI physician order, and the EMR banner also reflected DNR/DNI, but the record did not document that two physicians had certified a terminal or incurable condition as described in the resident’s Durable Power of Attorney. Resident 31’s EMR showed severe cognitive impairment, a DNR/DNI physician order, and an EMR banner reflecting DNR/DNI, but her Living Will stated that life-sustaining treatment should be provided if there was detectable brain activity and restoration of heartbeat should be attempted until there was no hope of regaining a heartbeat; there was no documentation that her wishes had changed since that document was signed. Interview with the DON confirmed there was no documentation in the EMRs for residents 5, 6, 7, 8, 12, 22, 31, 39, and 45 showing that the code status listed on the EMR banners had been discussed with the resident or representative to ensure the resident’s wishes would be followed if heart or breathing stopped. The provider’s October 2025 Code Status/Resuscitation policy stated that when a resuscitation decision is made, the physician must document the rationale supporting the order and the risks, benefits, and choices discussed with the resident and family.
Bed-Mounted Assistive Devices Installed Without Required Documentation and Manufacturer Compliance
Penalty
Summary
The facility failed to ensure that assistive devices attached to residents’ beds were installed and used in accordance with manufacturer instructions and facility policy. Surveyors found that for nine sampled residents with bed-mounted assistive devices, the facility did not document the date the devices were installed, and for several residents there was no documentation that alternatives were tried before the devices were placed, that a physician’s order was obtained, that a safety assessment was completed, or that informed consent was obtained. The report identified residents 1, 9, 10, 32, 34, 35, 36, 43, and 47 as having these devices on their beds. During observations, resident 9 had an assistive device attached to the right side of the bed and used it to reposition in bed, but she was unsure whether she had been educated about the risks and benefits. Her record lacked documentation of prior interventions, signed consent, a physician’s order, a quarterly assessment for safe use, and the installation date. Resident 34 had a device attached to the left side of the bed, and her record lacked documentation of prior interventions, signed consent, a physician’s order, a safety assessment, and the installation date. Resident 35 also had a device attached to the left side of the bed, with no documentation of prior interventions, a safety assessment, or the installation date. Additional observations showed resident 43 had mobility bars on both sides of the bed, with the right and left vertical poles positioned 30 inches and 23.5 inches from the head of the bed, respectively, and the horizontal bars 6 inches and 7 inches above the mattress. Resident 10 had mobility bars on both sides of the bed, with the right-side rail 29 inches from the head of the bed and 9 inches above the mattress; that rail moved when shaken. Resident 1 had assistive devices on both sides of the bed, resident 36 had a bed rail on the right side used to move from sitting to standing, resident 47 had a left assistive device noted in a nursing entry with consent signed, and resident 32 had a signed consent for a left assistive device. The facility coordinator stated he made his own mount bracket because he did not like the mount that came with the device, and the DON stated she was not aware the current devices were not compatible with the residents’ bed frames per the manufacturer’s manual. The facility policy required least restrictive methods first, physician orders, care plan inclusion, quarterly review, and documentation of usage, and the Invacare manual stated to use only Invacare rails and accessories with Invacare beds, warning that non-Invacare accessories may increase the risk of injury or death.
Rusty Walk-In Refrigerator Shelf Contaminated Uncovered Raw Vegetables
Penalty
Summary
The provider failed to ensure that one of one walk-in refrigerators was free from rust on a metal wire storage shelf, and rust flakes had fallen onto uncovered raw vegetables stored on that shelf. During observation in the kitchen walk-in refrigerator, four metal wire shelves were seen, with rust present on the shelves and rust flakes on the floor. The bottom shelf held several cardboard boxes of raw vegetables, including a box of onions with rust flakes on them. The food service manager stated he was aware of the rust on the shelves and acknowledged that rust could flake off onto uncovered raw foods such as vegetables, and that if rust landed on a vegetable like a broccoli stalk it could not be cleaned off and could potentially end up in residents' meals. The provider's September 2025 Standard Food Storage Guidelines stated that food storage areas should be clean to prevent contamination and illness to residents.
Deficiency in Nutritional Care for Resident with Significant Weight Loss
Penalty
Summary
The report identifies a deficiency in the nutritional care provided to a resident at risk of significant weight loss. The resident, who has a history of Dupuytren's contracture, anorexia, chronic kidney disease, diabetes, and Alzheimer's Dementia, was observed struggling to eat independently due to his physical limitations. Despite recommendations for an occupational therapy evaluation for adaptive silverware, this was not completed due to the unavailability of an occupational therapist. The resident's care plan indicated he was independent with eating, but observations showed he required assistance, which was not consistently provided. The facility failed to implement and monitor nutritional interventions effectively. The resident experienced significant weight loss over several months, dropping from 134 pounds to 117 pounds. Although the registered dietitian noted the weight loss and recommended nutritional supplements and an enhanced food program, these interventions were not consistently applied. The resident was not always provided with the necessary dietary supplements, and there was confusion among staff about whether he was on the enhanced food program. Communication and policy adherence issues were also evident. The facility's policies required timely physician notification of significant weight changes, but there was uncertainty among staff about who was responsible for this task. The resident's weight loss was not promptly communicated to the physician, and the facility's reweigh policy was not consistently followed. Additionally, the resident's dietary needs, such as the provision of adaptive silverware and consistent meal assistance, were not adequately addressed, contributing to the deficiency in care.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and sanitation practices in the kitchen, as observed during a survey. Items were improperly stored under the food preparation sink, including a green bucket with an unknown black liquid, a rusted pie plate, and various kitchen utensils. Additionally, the facility did not maintain adequate documentation for the cleaning and sanitation of the dishwasher, with missing records for chemical concentrations and cleaning logs over several days. The facility also lacked a process to test and document sanitation levels in sanitation buckets, which were used to wipe surfaces in the kitchen. Observations revealed that staff did not consistently test the chemical concentration of the sanitizing solution, and there was no log to document these concentrations. Furthermore, refrigerator and freezer temperatures were not consistently documented, with several days missing records, and food temperatures were not measured or documented prior to serving. During meal services, proper food handling processes were not followed by CNAs and dietary staff. Staff were observed using gloves inappropriately, such as not changing gloves between tasks or failing to perform hand hygiene. Additionally, resident refrigerators were not consistently monitored for temperature, and expired food was found in some refrigerators. The facility's policies on food safety and sanitation were not adhered to, contributing to these deficiencies.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection prevention practices, as evidenced by multiple observations and interviews. A resident on enhanced barrier precautions did not have the required personal protective equipment (PPE) used by staff during care. Specifically, an LPN did not wear a gown while changing a dressing, and hand hygiene was not performed after glove removal. Another resident with a pressure ulcer was not placed on enhanced barrier precautions, and staff did not wear gowns during wound care or other personal care activities. Additionally, the facility did not follow its policy for nebulizer tubing changes. A resident's nebulizer set was not replaced as required, and documentation discrepancies were noted regarding the tubing change. The facility's beauty shop and tub room were found to have improperly stored and unclean multi-use items, with visibly soiled containers and equipment. Staff interviews revealed inappropriate cleaning practices, such as using alcohol pads instead of the recommended disinfectant wipes. Hand hygiene and equipment disinfection were also inadequate. An RN was observed placing supplies on a soiled surface without cleaning it or using a barrier, and vital signs equipment was not disinfected between resident uses. The infection preventionist confirmed gaps in staff training and monitoring, and the facility's policies on enhanced barrier precautions, hand hygiene, and equipment disinfection were not consistently followed.
Improper Storage of Hazardous Materials in Beauty Shop
Penalty
Summary
The facility failed to ensure the proper storage of hazardous products and sharp objects in the beauty shop, leading to potential accident hazards. During an observation, it was noted that the beauty shop door was open and unattended, with various beauty products and supplies stored in unsecured cupboards and drawers. These products included items with warning labels indicating they should be kept out of reach of children, were flammable, or could cause irritation. Additionally, cutting scissors were found in an unsecured drawer, accessible to residents. A specific incident involved a resident who was observed looking into the open beauty shop door before being redirected by staff to the dining room. The Director of Nursing (DON) was interviewed and revealed uncertainty about who was responsible for maintaining the beauty shop's safety, suggesting it might be the activities department. The facility's storage policy did not cover the beauty shop or resident environment areas, indicating a lack of clear guidelines for the safe storage of hazardous materials in these areas.
Deficiency in Controlled Medication Management
Penalty
Summary
The facility failed to establish and maintain a process to accurately identify, reconcile, and appropriately secure and store scheduled controlled medications. During an observation and interview, it was revealed that the medication storage room used a keyless lock entry system, and two medication carts were stored inside. These carts contained drawers with residents' individualized medication cards and stock medications, including scheduled controlled medications. However, there were no reconciliation or tracking records for these scheduled controlled medications, except for PRN controlled medications and Fentanyl patches. Interviews with the Director of Nursing (DON) and other staff members highlighted a lack of reconciliation and tracking for scheduled controlled medications. The DON admitted that while PRN controlled medications were tracked, scheduled controlled medications were not. The process required two nurses to count and reconcile these medications each shift, but this was not consistently followed. Additionally, the consultant pharmacist confirmed that the facility did not have reconciliation records for scheduled controlled medications, and the responsibility for monitoring these medications was left to the nurses. Further interviews and observations revealed that the facility's electronic medical record (EMR) system did not automatically reconcile scheduled controlled medications, and there was no report available to identify residents with ordered controlled medications. Nurses had to manually check each medication bubble pack to identify residents receiving scheduled controlled medications. The facility's policy required controlled substances to be properly acquired, stored, and reconciled, but these procedures were not adequately implemented, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Eureka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ashley Medical Center Nursing Home | 22.1 mi | ★★★★★ | 0 | 0 |
| Bowdle Nursing Home | 22.1 mi | ★★★★★ | 0 | 0 |
| Walworth County Care Center, Inc | 27 mi | ★★★★★ | 6 | 0 |
| Wishek Living Center | 33.8 mi | ★★★★★ | 0 | 0 |
| Strasburg Nursing Home | 36.6 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avera Eureka Health Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.