Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Bethesda Of Beresford during CMS and state inspections, most recent first.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
Surveyors found that staff did not consistently document completion of kitchen cleaning tasks or coffee temperature checks, and a dietary aide failed to perform required hand hygiene before and after handling food and serving meals. These actions were not in accordance with the facility's policies for sanitation and infection prevention.
A resident with an open surgical wound on the ear was not placed on enhanced barrier precautions as required by facility policy. Observations showed no signage or PPE available, and staff confirmed that EBP had not been implemented since the surgical procedure, despite the resident's ongoing wound care needs.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
The facility failed to provide Bed Hold Notices to four residents prior to their transfer to the emergency department for various medical conditions. Although emergency contacts were notified, there was no documentation of bed hold notifications. The administrator misunderstood who was responsible for issuing these notices, leading to the deficiency.
The provider failed to ensure sufficient nursing staff to answer call lights in a reasonable time for five residents. One resident reported waiting 20 to 30 minutes, another noticed longer wait times at night, and a third sometimes waited for hours at night. A resident experienced long wait times that led to incontinence episodes, and another's call light was non-functional for two days. The night shift staffing consisted of only one CNA and one nurse, contributing to the longer wait times.
The provider failed to follow necessary food safety guidelines for storage, labeling, and sanitation in the kitchen. Observations revealed undated and dented cans, expired chlorine testing strips, improper chemical storage, and significant dust and grime on kitchen equipment. Interviews indicated a lack of awareness and adherence to protocols, with no consistent cleaning schedules or logs for the kitchen and ice dispensers.
The provider failed to ensure accurate PBJ data submission to CMS for three federal fiscal quarters, resulting in deficiencies such as excessively low weekend staffing and failure to have licensed nursing coverage 24 hours per day. The inaccuracies were identified through a review of PBJ data, staff schedules, and timecards, and confirmed by the administrator.
The provider failed to address Legionella monitoring and prevention in the infection control program, potentially affecting all 35 residents. The administrator and maintenance director confirmed no water testing for Legionella had been performed, and the city's municipal water department did not monitor for it. The facility had no Legionella monitoring or prevention plan.
The provider failed to maintain a clean and homelike environment in several areas, including the activities room, resident rooms, mechanical lifts, hand sanitizer dispensers, and the scale room. Observations revealed clutter, dust, dirt, and damaged surfaces, while interviews with staff highlighted systemic issues in cleaning and maintenance routines. The Maintenance Requisition log showed incomplete requests, indicating poor communication and follow-up.
The provider failed to make grievance information and forms readily available to residents and their representatives. Residents were unaware of the grievance official and how to file a grievance. Observations showed that grievance information was not in prominent locations, and the forms were kept out of residents' reach. The admission packet and grievance policy also lacked specific details about the grievance official and the process.
The provider failed to ensure expired medications were not administered to residents and did not remove and discard expired medications from two medication carts. Observations revealed several bulk medications past their expiration dates, and interviews with staff confirmed that expired medications were missed and left on the cart. The facility's policy required proper labeling, storage, and disposal of expired medications, but these guidelines were not followed.
The provider failed to ensure the regular safety inspection of bed rails for two residents. One resident, who had a stroke and limited mobility, had bed rails in the up position but was not observed using them. Another resident had a bed rail near the wall but did not use it. The maintenance director did not assess or monitor the bed rails, contrary to the facility's policy requiring regular maintenance and individual evaluations.
The provider failed to ensure the resident call light system was functioning for two residents. One resident reported waiting hours for assistance, and observations confirmed the call light did not activate properly. Another resident's call light malfunctioned, and staff provided a different one. The facility lacked regular preventative maintenance and had an unreliable call light system computer program.
The provider failed to ensure that the contact information for the ombudsman and the SD DOH was posted in accessible locations for all residents, visitors, and families. Residents were unaware of how to contact the ombudsman or file a complaint with the SD DOH, and the admission handbook contained incorrect and outdated contact information.
The provider failed to make the most recent survey results accessible to all residents and their representatives. Residents were unaware of their right to read the state survey results or where to find them. Observations confirmed that the survey results were not made available, and the administrator confirmed that the survey binder had been removed from the front lobby in January 2024 after a water leak. The facility resident rights document indicated that survey results should be located at the nurses' station and next to the business office.
The provider failed to update a resident's code status from full code to DNR in their medical records, despite a care conference note and an Expression of Healthcare Preferences form indicating the change. The administrator admitted that the necessary steps to update the physician's orders and the EMR dashboard were not completed.
The provider failed to develop, revise, and implement comprehensive care plans for two residents, leading to deficiencies in nail care and range of motion exercises. One resident did not receive necessary hand splint use and exercises, while another had inadequate nail care and range of motion interventions. The care plans were not updated to reflect changes in the residents' conditions, resulting in inadequate care.
The provider failed to ensure ongoing restorative nursing programs for two residents with hemiplegia and hemiparesis, resulting in a lack of range of motion exercises and use of prescribed splints. Both residents expressed dissatisfaction with the absence of these programs, and the Director of Nursing confirmed that they had not been assessed or provided with necessary restorative care.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report excerpt.
Failure to Consistently Follow Food Safety and Sanitation Practices
Penalty
Summary
Surveyors identified multiple failures in the facility's food safety and sanitation practices. Observations revealed that weekly kitchen cleaning tasks were not consistently documented as completed, with 13 out of 40 tasks unmarked for one week and 14 out of 40 for another. Additionally, temperature monitoring and documentation for the coffee machine were incomplete, with only 6 out of 33 required temperature checks recorded. Staff interviews indicated confusion regarding whether temperature checks were still required after the coffee machine was calibrated, despite the dietary manager and administrator expecting ongoing monitoring and documentation. Hand hygiene practices were also found to be deficient. A dietary aide was observed failing to perform hand hygiene before and after checking food temperatures, serving meals, and handling resident food items. The aide acknowledged that hand hygiene should have been performed at these times. The facility's policies required staff to maintain sanitation through a comprehensive cleaning schedule and to practice accepted hand hygiene to prevent infection, but these standards were not consistently followed as evidenced by the observations and staff interviews.
Failure to Implement Enhanced Barrier Precautions for Resident with Open Surgical Wound
Penalty
Summary
A deficiency was identified when a resident with an open surgical wound on the right ear, resulting from the removal of squamous cell carcinoma, was not placed on enhanced barrier precautions (EBP) as required by facility policy. Observations revealed the resident had a bandaged ear with visible blood, and the electronic medical record documented a slow-healing surgical wound with drainage and red, lump-like tissue. Despite these findings, there was no documentation of EBP implementation in the resident's record. Further observations showed there were no signs indicating EBP inside or outside the resident's room, nor was personal protective equipment (PPE) such as gowns and gloves available for staff use during contact care. During wound care, a registered nurse used gloves but did not utilize a gown, and confirmed that EBP had not been initiated since the surgical procedure. The interim director of nursing/infection preventionist acknowledged that EBP should have been in place for the resident due to the open wound, in accordance with the facility's policy.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Failure to Provide Bed Hold Notices for Hospitalized Residents
Penalty
Summary
The provider failed to ensure that a Bed Hold Notice form was given to four sampled residents prior to their transfer to the emergency department. Each of these residents required hospitalization for various medical conditions, including nausea/vomiting, gastrointestinal bleeding, sepsis, and pneumonia. Despite notifying the residents' emergency contacts or power of attorneys about the need for emergency room evaluations, there was no documentation found regarding the notification of the residents' bed hold status. An interview with the administrator revealed that there was a misunderstanding about who was responsible for issuing the bed hold notices. The administrator believed that the business manager was handling the notices, but this was not the case. The facility's policy stated that a bed would be held for the resident during their absence if the resident or responsible party agreed to pay the established base room rate, and that consent should be obtained within 48 hours of transfer. However, this policy was not followed, resulting in the deficiency.
Insufficient Nursing Staff Leads to Long Call Light Wait Times
Penalty
Summary
The provider failed to ensure there were sufficient nursing staff to answer call lights in a reasonable time for five of thirty-five sampled residents. Resident 4 reported waiting 20 to 30 minutes for someone to answer his call light, with the longest wait time being 40 minutes. Resident 3 noticed longer wait times at night, with 19 instances of wait times over 15 minutes and the longest being 30 minutes. Resident 5 sometimes waited for hours at night, and her call light was found to be non-functional due to a dead battery, with one instance of a 40-minute wait time. Resident 21, who was there for therapy after a hip fracture, experienced long wait times that led to incontinence episodes, with the longest wait time being 109 minutes. Resident 13's daughter also noticed longer wait times, usually around 30 minutes, and the resident's call light was non-functional for two days. The night shift staffing consisted of only one CNA and one nurse from 10:00 p.m. to 6:00 a.m., which contributed to the longer wait times. The facility's call light policy did not define an acceptable time frame for answering call lights. Interviews with staff revealed that some charted continence status immediately, while others did so later, potentially leading to discrepancies in records. The administrator acknowledged awareness of the long call light wait times and noted that the night shift staff consisted of one CNA and one nurse, with a 30-minute overlap between shifts to provide time for shift-to-shift reports. The resident council also reported difficulties in getting staff to answer call lights in the evening, with one resident waiting in the bathroom for 45 minutes and another calling the facility on her cell phone after waiting more than 20 minutes. The facility's revised call light policy aimed to ensure residents always had a method of calling for assistance and that staff responded promptly, but it did not specify an acceptable response time. The staffing schedules confirmed the limited night shift staffing, which likely contributed to the long wait times experienced by the residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The provider failed to ensure necessary food safety guidelines were implemented and followed for appropriate storage and labeling of food and chemical items, appropriate monitoring of the low-temperature dishwasher, and cleaning and sanitary maintenance of the kitchen. Observations revealed multiple issues including undated and dented cans in the dry storage room, expired chlorine testing strips, and improper storage of chemicals near food preparation areas. Additionally, there was significant dust and grime on ceiling vents, kitchen equipment, and utensils, as well as food build-up in various kitchen appliances and areas. Interviews with staff members, including the dietary manager and maintenance director, indicated a lack of awareness and adherence to proper food safety and sanitation protocols. The dietary manager admitted to not dating cans upon receipt and being unaware of the expired chlorine testing strips. There were no consistent cleaning schedules or logs for the kitchen and ice dispensers, and the dietary manager was observed handling food without wearing a beard net, contrary to the facility's policy. The facility's policies on sanitation, food storage, and dishwasher maintenance were not followed, leading to the observed deficiencies. The ice dispensers had not been cleaned in the last six months, and there were no logs to document their cleaning. The provider's policies required proper labeling and dating of leftovers, regular checking of expiration dates, and the use of a comprehensive cleaning schedule, none of which were adequately implemented, resulting in the identified deficiencies.
Inaccurate PBJ Data Submission
Penalty
Summary
The provider failed to ensure that Payroll Based Journal (PBJ) data was accurately completed before submission to the Center for Medicare and Medicaid Services (CMS) for three of four federal fiscal quarters. Specifically, the PBJ data for Quarter 2, 2023; Quarter 3, 2023; and Quarter 1, 2024, contained inaccuracies. The inaccuracies included excessively low weekend staffing for Quarter 3, 2023, and failure to have licensed nursing coverage 24 hours per day on multiple dates across all three quarters. These deficiencies were identified through a review of the PBJ data submitted to CMS, staff schedules, and timecards, as well as interviews with facility staff. The administrator confirmed that the staffing schedules were correct and that the facility had met the requirement to have licensed nursing coverage 24 hours per day on the dates in question. However, the administrator was unaware that the staffing data had been inaccurately submitted to CMS. The former business office manager, who was responsible for submitting the staffing data, had stopped working for the facility in October 2023. The administrator speculated that the former employee had been submitting the staffing data incorrectly but was unsure why the most recent quarter's staffing data was also incorrect.
Lack of Legionella Monitoring and Prevention
Penalty
Summary
The provider failed to ensure that Legionella monitoring and prevention were addressed in the infection control program, potentially affecting all 35 residents within the facility. The infection prevention and control program, reviewed on 10/27/21, lacked any mention of Legionella prevention and monitoring. During an interview on 4/25/24, the administrator was unaware of any water testing for Legionella, and the Director of Nursing, who was the infection preventionist, was not available for an interview. The Maintenance Director revealed that no testing for Legionella had been performed on the facility's water supply, which was connected to the city's municipal water system. The city's municipal water department confirmed they did not monitor for Legionella, only the pH of the water supply. The Maintenance Director confirmed that the water had not been tested for Legionella in the three years he had been working at the facility. The administrator confirmed that there was no Legionella monitoring or prevention plan as part of the facility's infection control program.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The provider failed to maintain a clean and homelike environment in several areas of the facility, including the activities room, resident rooms, mechanical lifts, hand sanitizer dispensers, and the scale room. Observations revealed clutter, dust, dirt, and damaged surfaces in these areas. For instance, the activities room had glitter, confetti, and various art supplies scattered around, while the scale room had stained carpets and an unclean scale. Multiple resident rooms had issues such as sharp edges, clutter, and dirty surfaces, which were confirmed through both observation and resident interviews. Additionally, mechanical lifts were found to be filthy and missing safety components, and hand sanitizer dispensers were soiled with congealed sanitizer and dust. Interviews with staff members, including a CNA, environmental services technician, and maintenance director, highlighted systemic issues in the facility's cleaning and maintenance routines. The environmental services technician admitted to being the only housekeeper for the week and acknowledged that there was no regular deep cleaning schedule for long-term residents. The maintenance director revealed that he kept a mental note of repairs needed and performed room checks only once a month. He also mentioned that larger repairs were usually done when residents moved out. The CNA confirmed that nursing staff were responsible for cleaning mechanical lifts but admitted there were cleanliness concerns. Review of the provider's Maintenance Requisition log showed that several maintenance requests had not been completed, including a request to fix a hole in a wall and exposed bed control cord wires. The log also contained a note indicating that housekeeping was not following up on requests. These findings indicate a lack of effective communication and follow-up between housekeeping, maintenance, and nursing staff, contributing to the overall deficiency in maintaining a clean and homelike environment for residents.
Failure to Provide Accessible Grievance Information
Penalty
Summary
The provider failed to make information on how to file a grievance and the location of grievance forms readily available to residents and their representatives. During an interview with the resident council, it was revealed that residents were unaware of who the grievance official was and how to file a grievance. Observations of the facility's lobby and public areas showed that the grievance official's contact information, instructions on how to file a grievance, and the grievance forms were not in prominent locations. The administrator confirmed that she was the grievance official and expected residents to write grievances on regular paper, which she would then transfer to the official form. However, the information on the grievance process was not easily accessible, and the forms were kept in a location where residents could not reach them due to concerns about a resident who had a habit of taking items from the nurses' station. The review of the provider's admission packet and grievance policy revealed further deficiencies. The admission packet mentioned that forms were available by the front office but did not specify who the grievance official was or include a grievance form. The grievance policy stated that information on the internal grievance process would be provided upon request but did not specify who the grievance official was. Despite a plan of correction being implemented after a previous survey, the facility was still found to be non-compliant in making grievance information and forms readily accessible to residents and their representatives.
Expired Medications Not Removed from Medication Carts
Penalty
Summary
The provider failed to ensure expired medications were not administered to residents and did not remove and discard expired medications from two medication carts. Observations revealed several bulk medications past their expiration dates, including Senna, TUMS, multivitamins, calcium tablets, aspirin, Milk of Magnesia, and Tylenol. Interviews with LPN F and RN K confirmed that the dates written on the bottles were the dates they were opened, and some expired medications were missed and left on the cart. Both nurses acknowledged that expired medications should have been removed and disposed of properly. The facility's policy stated that medications should be labeled and stored according to professional principles, and expired medications should be disposed of according to procedures. The policy also required nurses to check expiration dates before administering medications. Despite these guidelines, expired medications were found on the medication carts, indicating a failure in adherence to the policy. The administrator acknowledged the issue and mentioned that the director of nursing was unavailable due to personal reasons, and the pharmacist had recently audited the medications.
Failure to Ensure Regular Safety Inspection of Bed Rails
Penalty
Summary
The provider failed to ensure the regular safety inspection of bed rails for two residents. Resident 7, who had a stroke five years ago and could not use her right leg or arm, had bed rails on her bed in the up position. She mentioned using the bed rails sometimes for repositioning. However, a CNA stated that she never observed Resident 7 using the bed rails. Resident 2, who was sitting in her wheelchair while a CNA made her bed, had a bed rail near the wall, but the CNA stated that the resident did not use the bed rail. Resident 2 did not respond when questioned about the use of the rail. The maintenance director revealed that he did not assess the bed rails, did not have measurements or any log with bed rail information, and did not perform annual checks or monitoring of the bed rails once they were placed on the residents' beds. The facility's Bed Inspection and Bed Rail Policy stated that regular maintenance and individual bed rail evaluations were required to ensure safety, but these procedures were not followed. The policy also mentioned that the facility would provide education to residents or their representatives about the risks and benefits of bed rail use, which was not evident in the findings.
Resident Call Light System Malfunction
Penalty
Summary
The provider failed to ensure the resident call light system was functioning for two of the sampled residents. Resident 5 reported waiting hours at night for assistance when using her call light. During an observation, it was noted that the call light did not activate the red indicator light, and there was no indication outside the room that the call light was on. A CNA confirmed that the call light was not working and took it to maintenance for repair. The LPN also confirmed the malfunction and mentioned that someone would have to report the issue for it to be addressed. The call light audit report showed no record of the call light activation at the time it was pressed, and it only started working again after a delay. There was no regular preventative maintenance for the call lights, and staff reported issues verbally or in a maintenance request book, which was not always followed up on promptly. Resident 13's daughter reported a similar issue where the call light was not working, and staff had to provide a different call light. The administrator acknowledged the problem and mentioned that the call light system's computer program was unreliable, causing further complications in reassigning call lights to the correct room numbers. The maintenance director confirmed the lack of a preventative maintenance program and stated that issues were addressed only when reported. The call light audit for Resident 13 showed a low battery signal and subsequent malfunction, with a new call light provided days later. The provider's maintenance requisition records showed unresolved call light issues, and the call light policy lacked procedures for handling malfunctions and regular maintenance checks.
Failure to Post Ombudsman and SD DOH Contact Information
Penalty
Summary
The provider failed to ensure that the contact information for the ombudsman and the South Dakota Department of Health (SD DOH) was posted in a location accessible to all 35 current residents, visitors, and families. During an interview with the resident council, it was revealed that the residents were unaware of where to find the ombudsman's contact information and did not know they could contact the SD DOH directly or file a complaint. Observations confirmed that the ombudsman's contact information was posted in the entryway vestibule, which required a door code to access, and in the social worker's office, which was not always accessible to residents. Additionally, there was no SD DOH contact information or a statement that residents could file a complaint with the SD DOH posted anywhere in the facility. The administrator confirmed that the ombudsman's contact information was only posted in the social worker's office and that the SD DOH contact information was not posted. The admission handbook was also found to be deficient, as it contained incorrect and outdated contact information for the state ombudsman program and the SD DOH complaint coordinator. The table of contents listed State and Federal Contacts on page 19, but there was no page 19, and the contact information started on page 18, followed by a mislabeled page 2. This lack of accessible and accurate information prevented residents from knowing how to file complaints or seek assistance from the ombudsman or SD DOH.
Failure to Make Survey Results Accessible to Residents
Penalty
Summary
The provider failed to make the most recent survey results accessible to all residents and their representatives. During an interview with the resident council, it was revealed that residents were unaware of their right to read the state survey results or where to find them. Observations of the lobby and public areas confirmed that the survey results were not made available. An interview with the administrator confirmed that the survey results were not currently posted and that the survey binder had been removed from the front lobby in January 2024 after a water leak. A review of the facility resident rights document in the admission packet indicated that residents have the right to examine the results of the most recent survey, which should be located at the nurses' station and next to the business office.
Failure to Implement Revised Advanced Directive
Penalty
Summary
The provider failed to implement a revised advanced directive for one resident. The resident's paper and electronic medical records indicated a full code status, despite a care conference note and an Expression of Healthcare Preferences form indicating a change to do not resuscitate (DNR). The administrator acknowledged that the necessary steps to update the resident's code status were not completed, including updating the physician's orders and the electronic medical record (EMR) dashboard. The administrator admitted that she did not follow up with the new Expression of Healthcare Preferences form, which should have been sent to the physician for signature and uploaded to the EMR. The facility's Denoting Code Status policy did not include the steps or expectations mentioned by the administrator, such as the use of a stamp to ensure the process was followed. This oversight resulted in the resident's code status not being accurately reflected in their medical records.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The provider failed to develop, revise, and implement a comprehensive person-centered care plan for two residents, specifically addressing nail care and range of motion exercises. Resident 3 had a right-hand splint and a schedule for its use, but she reported not wearing the splint for a long time and not receiving any range of motion exercises. The care plan for Resident 3 had not been updated after her discharge from occupational therapy, and there were no goals or interventions related to her right-hand contracture or limited range of motion in her right arm. The registered nurse and the administrator were unable to provide documentation or confirm the use of the hand splint for Resident 3, and there was no policy for the restorative nursing program in place. Additionally, the care plan had not been revised to reflect changes in Resident 3's condition and needs after her therapy ended. This lack of documentation and follow-up led to a failure in providing necessary care for Resident 3's condition, including the use of the hand splint and range of motion exercises. The interdisciplinary team did not adequately assess and update the care plan to address Resident 3's needs, resulting in a deficiency in her care. Resident 5 had long, jagged, and thickened fingernails with dark residue under the tips, and she reported not receiving exercises for her hands. Despite having a physician's order for a blue palm protector for her right hand, there was no documentation of nail care or refusal of nail care in her records. The care plan for Resident 5 did not include any interventions related to her limited range of motion or nail care. Interviews with staff revealed inconsistencies in the provision of nail care and the use of the blue palm protector. The director of nursing confirmed that Resident 5 had not been assessed for a restorative program, and the care plan was not updated to reflect her current needs. This lack of proper assessment and documentation led to a deficiency in providing necessary care for Resident 5's condition, including nail care and range of motion exercises. The provider's care planning process policy emphasized the importance of a comprehensive, individualized plan of care for each resident, but this was not followed for Residents 3 and 5. The interdisciplinary team failed to assess, individualize, and evaluate the effectiveness of the care plans, resulting in deficiencies in addressing the residents' needs and conditions. The care plans were not revised on an ongoing basis to reflect changes in the residents' conditions and the care they were receiving, leading to inadequate care for both residents.
Failure to Implement Restorative Nursing Programs
Penalty
Summary
The provider failed to ensure an ongoing restorative nursing program for two residents at risk for a decline in range of motion (ROM). Resident 3 had a right-hand splint with a wearing schedule posted in her room, but she indicated she had not worn the splint for a long time and was not receiving any range of motion exercises. Her medical records showed a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, affecting her right side, and a contracture of the right hand. Despite these conditions, there was no documentation supporting her participation in a restorative program, and her care plan lacked interventions related to her right-hand contracture. The Occupational Therapy Discharge Summary indicated a splint and brace program, but there was no follow-up in the electronic medical record (EMR) to ensure compliance with this program. Similarly, Resident 5, who had hemiplegia and hemiparesis following a cerebral infarction affecting her left side, was observed with minimal movement in her hands and expressed dissatisfaction with not receiving exercises for her hands. Her medical records included a physician order for a palm protector due to contracture, but there was no evidence of a restorative program in place. Interviews with therapy staff revealed that both residents should have had restorative programs, but these were not implemented. The Director of Nursing (DON) acknowledged that not all residents had been assessed for restorative programs and that Residents 3 and 5 had not been evaluated or provided with such programs, despite their needs.
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 56 citations issued within 25 miles in the last 12 months — 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 Beresford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alcester Care And Rehab Center, Inc | 9.1 mi | ★★★★★ | 2 | 0 |
| Centerville Care And Rehab Center Inc | 9.1 mi | ★★★★★ | 0 | 0 |
| Hillcrest Health Care Center | 16.1 mi | ★★★★★ | 30 | 0 |
| Pioneer Memorial Nursing Home | 16.4 mi | ★★★★★ | 0 | 0 |
| Wakonda Heritage Manor | 17 mi | ★★★★★ | 5 | 0 |
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