Above 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 Seven Sisters Living Center during CMS and state inspections, most recent first.
The facility did not routinely complete Abnormal Involuntary Movement Scale (AIMS) assessments for residents prescribed antipsychotic medications, as confirmed by record reviews and staff interviews. Several residents with diagnoses such as schizophrenia, Alzheimer's disease, and dementia were receiving antipsychotic drugs without documented AIMS assessments, and staff acknowledged the absence of a policy or recent assessments for monitoring adverse side effects.
The facility did not screen all residents for trauma history upon admission, as required by its policy. Several residents with cognitive impairment, PTSD, or a history of abuse were not assessed for trauma or related triggers, and their care plans lacked appropriate interventions. Staff interviews confirmed that trauma screening was not routinely performed unless a mental health diagnosis was present, and trauma-informed care training had not been provided to all staff.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility did not ensure that dialysis care was provided according to the resident's needs.
A resident with intact cognition and multiple medical conditions sustained a burn to her hand after warming it on a baseboard heater in a lounge area. The heater's accessible temperature controls and high surface temperatures were not previously identified as hazards, and no interventions were in place to prevent such accidents. Staff were unaware of the risk, and other residents also frequented the area without prior incidents.
A resident, who was cognitively intact, experienced verbal abuse from a cook during a meal after expressing displeasure with the cook's attitude. The cook responded with vulgar language and told the resident to starve, leading the resident to report the incident to a CNA, who then informed an LPN. The cook had a prior history of disciplinary issues and had previously received training on abuse and patient rights.
The facility failed to ensure proper infection control practices, including hand hygiene and equipment sanitization, during resident care. Staff did not follow protocols for glove use and handling of soiled linens, and there was inadequate documentation and adherence to policies for oxygen tubing replacement. Additionally, cleaning of multi-use recliners and a couch in the memory care unit was insufficient.
Two residents receiving specialized diets were not served correct portion sizes or nutritionally balanced meals. Observations showed they received only a small portion of ground spaghetti without additional food items. Interviews revealed inadequate training for dietary staff, including a newly hired cook and dietary manager, on serving sizes and specialized diets. Both residents had significant weight loss and specific dietary needs that were not met.
Failure to Complete Routine AIMS Assessments for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that Abnormal Involuntary Movement Scale (AIMS) assessments were routinely completed for residents receiving antipsychotic medications. Record reviews for five sampled residents revealed that none had current or consistently completed AIMS assessments documented in their electronic medical records. These residents had various diagnoses, including schizophrenia, Alzheimer's disease, dementia, and depression, and were prescribed antipsychotic medications such as risperidone, olanzapine, and quetiapine. In some cases, the last AIMS assessment was completed several months prior, while in others, there was no evidence of any AIMS assessment being performed since admission. Interviews with facility staff confirmed the lack of routine AIMS assessments. The lead resident care manager stated that AIMS assessments should be completed upon admission, quarterly, and with any significant change in status, but acknowledged that recent assessments could not be found for residents on psychotropic medications. The MDS coordinator also confirmed that no AIMS assessments had been completed upon admission or during the MDS process. Additionally, the facility did not have a psychotropic medication policy in place and was unable to provide one for review.
Failure to Screen Residents for Trauma History Upon Admission
Penalty
Summary
The facility failed to ensure that all residents were screened for a history of trauma upon admission, as required by their own policy. Four residents with varying degrees of cognitive impairment and mental health diagnoses were not assessed for trauma history or triggers at the time of their admission. For example, one resident with severe cognitive impairment disclosed a history of childhood abuse and expressed ongoing concerns about personal safety, yet there was no documentation of trauma screening or assessment for trauma triggers in her record. Another resident with a history of abuse and multiple hospitalizations related to trauma was not screened for trauma upon admission, and her care plan did not specifically address her trauma history. Interviews with facility staff, including the social services manager and lead resident care manager, confirmed that there was no process in place for universal trauma screening at the time of admission. Staff indicated that only residents with a mental health diagnosis or those prescribed psychotropic medications were referred for psychiatric evaluation, and trauma-informed care had not been part of the training curriculum. Staff were unaware that trauma screening was required for all residents, regardless of diagnosis. Additional residents with diagnoses of PTSD, including one with a history of the Oklahoma City bombing and another receiving psychiatric care through the VA, were also not screened for trauma upon admission. Their care plans either did not mention PTSD or lacked interventions related to trauma. Review of the facility's policy confirmed that universal trauma screening was required, but this was not implemented for the sampled residents, resulting in a failure to provide trauma-informed and culturally competent care as outlined in facility policy.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions 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.
Failure to Prevent Resident Burn from Baseboard Heater
Penalty
Summary
The facility failed to identify and implement interventions to prevent a resident from being burned by a baseboard heater in the lounge area next to the nurses' station. The lounge contained two metal baseboard heating units beneath large windows, each with accessible temperature control knobs and warning stickers indicating high temperatures. Staff interviews and record reviews revealed that the resident, who had intact cognition and diagnoses including malignant colon cancer, diabetes, and heart disease, frequently sat in this area due to feeling cold and was able to move her wheelchair independently. On the day of the incident, the resident reported right hand pain after warming her hand on the heater, which was found to be red and swollen. The baseboard heater's metal surface was later measured to reach temperatures up to 130 degrees Fahrenheit, exceeding the threshold capable of causing burns. Prior to the incident, staff were unaware that the baseboard heaters posed a burn hazard or that the temperature knobs were accessible and could be adjusted. The heaters had not been identified as an accident hazard, and no proactive measures had been taken to prevent such incidents. Other residents also regularly sat in the same area, but no previous burns had been reported. The facility's Accident Prevention and Resident Safety policy was requested, and an Accident and Incidents Investigating and Reporting policy was provided.
Failure to Protect Resident from Verbal Abuse by Dietary Staff
Penalty
Summary
A cognitively intact resident was subjected to verbal abuse by a cook during a supper meal. The incident began when the resident, seated at her dining table and using her tablet, noticed the cook looking at her. Upon asking what he wanted, the cook responded with a tone and attitude the resident found inappropriate. When the resident expressed her displeasure, the cook used vulgar language and told her to starve, prompting the resident to leave the dining room. The resident immediately reported the incident to a CNA, who recognized the behavior as verbal abuse and reported it to the LPN on duty. The LPN attempted to speak with the resident, who was upset, and then spoke with the cook. The cook admitted to using vulgar language but denied directing it specifically at the resident. The incident was subsequently reported up the chain of command, and the cook's supervisor was notified. Prior to this event, the cook had a documented history of disciplinary issues, including written warnings for smoking on campus, inappropriate behavior toward staff and management, and refusal to follow directions. The resident also indicated that this was not the first time the cook had used an inappropriate tone with her. The facility's records confirm that the cook had received training on abuse, neglect, and patient rights prior to the incident.
Infection Control Deficiencies in Resident Care and Equipment Maintenance
Penalty
Summary
The provider failed to ensure proper infection prevention and control practices across several areas of care. During a mechanical lift transfer and personal hygiene care for a resident, two staff members did not perform hand hygiene or glove changes appropriately. They handled soiled linens and resident care items without sanitizing their hands or changing gloves between dirty and clean tasks. Additionally, the mechanical lift used for the transfer was not sanitized after use, which is against the facility's policy for cleaning durable medical equipment. In another instance, a medication aide did not follow proper hand hygiene and glove use protocols during suprapubic catheter care for a resident. The aide handled clean dressings and other items with soiled gloves and failed to cleanse the catheter bag's drainage port after emptying it. The aide also placed soiled linens directly on the floor and handled them without gloves, further compromising infection control standards. The facility also failed to maintain proper documentation and adherence to policies regarding oxygen tubing replacement for residents on oxygen therapy. There was no documentation of when nasal cannulas were last replaced, and staff were uncertain about the facility's policy on tubing changes. Additionally, the cleaning and sanitization of multi-use recliners and a couch in the memory care unit were inadequate, with visible stains and wear not addressed by housekeeping staff.
Deficiency in Dietary Services and Portion Control
Penalty
Summary
The provider failed to ensure that two residents receiving specialized diets were served the correct portion sizes and nutritional values during a meal service. Observations revealed that residents were served only a small portion of ground spaghetti without any additional food items, contrary to the menu that included a salad and bread. Despite the presence of the administrator and a notification from an aide, no further food items were offered to the residents. Interviews with the residents' family members and staff highlighted issues with the residents' dietary needs and preferences, such as one resident's preference for soft foods and another's significant weight loss. Interviews with the registered dietitian and the administrator confirmed that the meals served were not visually palatable, accurate in portion size, or nutritionally balanced. The administrator acknowledged that the dietary staff, including a newly hired cook and dietary manager, had not been adequately trained on serving sizes and specialized diets. The dietary manager admitted to having received minimal training and lacked experience in a long-term care setting, while the dietary cook also lacked formal training on portion sizes and specialized diets. The residents involved had significant medical histories, including major neurocognitive disorders and weight loss. One resident was on hospice care with a diet order for a specific texture, while the other had a regular diet with mechanical texture and specific food preferences. Both residents experienced significant weight loss over a six-month period, which was not adequately addressed by the facility's dietary practices. The facility's policy on weight assessment and intervention was not effectively implemented, as evidenced by the lack of training for dietary staff on essential topics such as food safety, nutrition, and portion control.
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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 Hot Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Michael J Fitzmaurice South Dakota Veterans Home | 1.4 mi | ★★★★★ | 0 | 0 |
| Custer Care And Rehab Center | 25 mi | — | 38 | 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.