Below 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 Sunset Manor Avera Health during CMS and state inspections, most recent first.
Failure to Protect Resident from Physical Abuse During Incontinence Care: A CNA became combative during incontinence care for a resident with severe cognitive impairment, then straddled the resident in bed and applied pressure behind the ear while continuing care. The CNA later reported the incident to an LPN, who found no injuries, and the event was escalated through DON/MDS reporting.
Failure to timely report alleged abuse: A CNA straddled a resident in bed during incontinence care and used thumb pressure behind the resident’s ear to manage combative behavior while completing care. The incident was reported to an LPN and management, but the DON was not notified immediately and the allegation was not reported to the state survey agency within the required timeframe. The resident had no injuries noted after assessment.
Incomplete and Inaccurate Daily Nurse Staffing Postings: The facility failed to post daily nurse staffing information in a location readily visible to residents, staff, and visitors, and the postings often did not match actual hours worked. Surveyors found missing staffing forms for The Manor, TBI, and CBU on multiple days, several postings with no RN hours, and inaccurate entries that did not reflect shared RN shifts or staffing changes. LPN D, the administrator, and the DON all confirmed the postings were not consistently updated or accurate.
Inaccurate PASRR Coding on MDS Assessments: The facility failed to code MDS item A1500 accurately for multiple residents with serious mental illness, including residents with bipolar disorder, schizophrenia, psychotic disorder, depression, anxiety, and dementia. EMR review showed Level I PASRR screens indicating evidence of serious mental illness and, for several residents, prior Level II PASRR determinations, yet the MDS assessments were marked No for PASRR status. Interviews confirmed the SSD submitted PASRR screens to Maximus but did not enter PASRR data into the MDS, while the administrator stated the RN/MDS coordinator was responsible for accurate PASRR coding.
Staff failed to follow food safety standards during meal prep and service. A dietary assistant and cooks handled ready-to-eat foods, dirty linens, dishes, and resident meal items with bare hands or improperly used gloves, and pre-poured drinks were stored on open carts on resident trays. Food temperatures were not consistently checked or documented, and milk and chicken were found below the facility’s required safe holding temperatures before or during service.
Staff failed to follow infection control practices during resident transfers, feeding assistance, and care for residents on EBP. CNAs used mechanical lifts and slings without cleaning them between residents, did not perform hand hygiene after glove removal or between resident contacts, and handled food and care tasks with contaminated hands or gloves. CNAs also entered rooms of residents on EBP without wearing gowns and gloves during direct care and transfers, and one CNA continued care after perineal cleansing with the same gloves while adjusting a urinary catheter and assisting with the transfer.
Staff initiated and continued CPR on a resident with a documented DNR/DNI order, failing to verify and honor the resident's code status before and during resuscitation efforts. Despite code status information being available in the EMR and on hall sheets, staff performed CPR for about 20 minutes until the DON intervened and stopped the procedure after confirming the DNR status.
A resident with a history of sexually inappropriate behavior was not properly supervised, resulting in unsolicited sexual contact with another resident in a common area. Despite care plans and staff instructions requiring 1:1 supervision within arm's length, staff failed to monitor the residents as required, and did not intervene during the incident. Afterward, there was no immediate assessment or investigation, contrary to facility policy.
A resident with dementia was subjected to unsolicited touching by another resident with a history of sexually inappropriate behavior while unmonitored in a hallway. Staff failed to provide immediate intervention and did not complete a timely assessment of the affected resident's physical and emotional well-being, despite facility policies requiring close supervision and prompt evaluation after such incidents.
A resident with a history of stroke and limited mobility was transferred using a sit-to-stand lift without the required safety straps, resulting in a fall to the floor. Staff and documentation confirmed that the safety straps were not used, and the care plan lacked clear instructions regarding transfer methods and fall risk. The manufacturer's instructions for the lift, which require the use of safety straps, were not followed.
A resident with severe cognitive impairment ingested a Santimine tablet due to improper storage in an unlocked drawer. The resident was on 1:1 monitoring but accessed the tablets when one CNA was assisting another resident. The drawer lock was broken, and the tablets were left unsecured by a CNA. This incident highlights a lapse in supervision and adherence to hazardous materials storage policy.
A resident with a traumatic brain injury (TBI) did not receive adequate dining assistance and nutritional care due to a lack of specific care planning and staff training. The resident, who required assistance with eating, missed several evening meals because he refused to leave his room and was not allowed meal trays in his room. The care plan lacked specific instructions, and documentation of meal intake was inconsistent. The facility's policy to maintain residents' well-being was not followed.
A significant deficiency was identified in a TBI unit where an LPN failed to provide necessary repositioning and toileting assistance to residents as per their care plans. The residents, who had severe cognitive impairments and complex medical conditions, were left in soiled clothing and bedding. The neglect was discovered through a complaint, video footage, and staff interviews, revealing inadequate training and communication among staff.
In a TBI unit, eight residents did not receive care as per their care plans, with one resident found in the same clothes, cold, and covered in feces. Video footage showed staff, including LPNs and CNAs, not providing necessary care, spending time at desks, and lacking an ADL policy, contributing to the deficiency.
A facility failed to accurately complete elopement risk evaluations for several residents, including one with dementia who eloped undetected due to a malfunctioning door alarm. Despite previous elopement incidents, the resident's risk was not updated in the care plan, and staff did not recognize the event as reportable.
A cognitively impaired resident was physically restrained by an agency CNA without medical necessity, following her return from the hospital. The restraint, which involved holding the resident's arms and pressing the CNA's chin into her scalp, was not documented and only discovered through video footage review. The incident occurred in the facility's challenging behavior unit, and other staff present did not report the abuse.
Failure to Protect Resident from Physical Abuse During Incontinence Care
Penalty
Summary
The facility failed to protect a resident with severely impaired cognition from physical abuse during incontinence care. The resident had a BIMS score of 99 and diagnoses including neurocognitive disorder with Lewy Bodies, dementia with behavioral disturbances, and anxiety. His care plan directed staff to assist him with incontinence care and to support him in making safe decisions using simple choices. According to the facility-reported incident, a CNA was providing incontinence care when the resident became combative. The CNA straddled the resident in his bed to control the behavior and applied pressure with his thumb to a pressure point behind the resident's ear to calm him. The action increased the resident's combative response, and the CNA continued providing incontinent care while the resident was restrained. The incident was reported during shift report and then escalated through facility leadership and the SD DOH reporting process. An LPN later confirmed that the CNA described straddling the resident and placing pressure behind the ear while cleaning stool from the resident's perineal area. The LPN assessed the resident and found no injuries. The CNA, NM, and MDS nurse were later terminated, and the facility policy stated that staff must not physically abuse, mistreat, or neglect a resident and that abuse includes the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report a suspected physical abuse incident to the SD DOH within the required time frame for one resident who was combative during incontinence care. According to the incident report, a CNA turned the resident onto his side in bed, then straddled him by placing a leg over him and used a thumb to apply pressure to a pressure point under the resident’s ear to distract him and complete care. The resident became more combative during the interaction, and no injuries were found when the resident was later assessed. The CNA reported the incident to an LPN during morning shift report after the event, and the LPN notified the NM, who then informed the MDS nurse. An incident report was completed and placed under the DON’s office door, but the DON was not in the facility at the time because the incident occurred over the weekend. The DON later stated she became aware of the alleged abuse on the following day and confirmed that the incident had not been reported to the SD DOH in the required time frame. The CNA returned to work for the next scheduled night shift and continued providing direct contact care because the incident had not yet been reported to the DON or administrator. The facility’s abuse prohibition policy required alleged abuse, neglect, exploitation, misappropriation, injuries of unknown origin, corporal punishment, and involuntary seclusion to be reported immediately to the administrator and to state authorities in accordance with state law, including within 2 hours when abuse is alleged. The DON stated she expected immediate notification of any alleged abuse or neglect. The report also noted that the DON completed reporting to the SD DOH after becoming aware of the incident, but the initial reporting had not occurred within the required timeframe.
Incomplete and Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The provider failed to post the required nursing staffing information each day in a location readily visible to residents, staff, and visitors, and the posted information did not always clearly reflect the actual hours worked by nursing staff. From October 2025 through December 2025, the facility had missing staffing forms on multiple days for The Manor, the TBI unit, and the CBU, and several posted forms did not include RN hours. Surveyors observed on 12/29/25 that The Manor and CBU staffing information was posted on a bulletin board near the nurses' station in The Manor, but the posting included the date of 12/26/25 and census information and had no RN hours documented. On the same day, the TBI unit had no posted nurse staffing hours at all, and on 12/31/25 the posted staffing hours for The Manor and CBU again showed no RN hours for that day. Review of the staffing records showed numerous missing nurse staffing information forms across the three units during the review period. The Manor had no forms on 13 listed days, the TBI unit had no forms on many listed days throughout October, November, and December, and the CBU had no forms on multiple listed days in late October and December. The review also showed no documented RN coverage hours on several dates, and the provider's nurse staff schedules showed RN/MDS coordinator C and RN/ADON FF were scheduled on certain dates but those hours were not represented on the posted staffing forms. On 12/18/25, RN/ADON FF and DON B were scheduled to provide resident care due to an LPN calling in sick, but the posted staffing hours were not updated to reflect that change. Interviews confirmed the staffing postings were not accurate or consistently visible. LPN D stated the TBI staffing form was posted behind a desk in the common area, was to be completed daily, and was not updated when staffing changed during the shift; she also stated the TBI form inaccurately showed the nurse as scheduled on that unit for the entire 12-hour shift even though the nurse split time between the TBI and CBU units. The administrator and DON both stated the forms were supposed to be completed daily, updated for staffing changes, and accurately reflect hours worked, and the DON confirmed that the MDS coordinator and DON hours were submitted in PBJ but were not included on the posted staffing forms. The facility assessment also stated that staffing was evaluated each shift and that there was at minimum one RN/LPN in the facility at all times for 24-hour nursing coverage.
Inaccurate PASRR Coding on MDS Assessments
Penalty
Summary
The facility failed to ensure accurate MDS coding for PASRR status for six sampled residents with serious mental health illness. Record review showed that residents 2, 6, 9, 34, 39, and 40 each had diagnoses or PASRR findings indicating serious mental illness, including bipolar disorder, psychotic disorder, schizophrenia, depression, anxiety disorder, and related conditions. For each of these residents, the EMR contained Level I PASRR information showing evidence of serious mental illness and, in several cases, prior Level II PASRR determinations, yet the corresponding MDS assessments were coded "No" for item A1500, which asks whether the resident is currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident 2 had bipolar disorder, neurocognitive disorder, and psychotic disorder, with a Level I PASRR stating evidence of serious mental illness and a prior Level II PASRR dated 1/18/23, but the 10/9/25 comprehensive MDS coded A1500 as No. Resident 6 had depression, anxiety disorder, and psychotic disorder, with a Level I PASRR stating evidence of serious mental illness and a prior Level II PASRR referenced in the PASRR screen, but the 5/8/25 comprehensive MDS coded A1500 as No. Resident 9 had depression, anxiety disorder, psychotic disorder, and schizophrenia, with a Level I PASRR stating evidence of serious mental illness and a prior Level II PASRR dated 11/14/18, but the 2/28/25 comprehensive MDS coded A1500 as No. Resident 34 had depression, anxiety disorder, and bipolar disorder, with a Level II PASRR dated 7/14/23, but the 7/6/25 comprehensive MDS coded A1500 as No. Resident 40 had depression, anxiety disorder, and psychotic disorder, with a Level I PASRR stating evidence of serious mental illness and a prior Level II PASRR dated 3/11/25, but the 3/31/25 comprehensive MDS coded A1500 as No. Resident 39 had Parkinson's disease, dementia, major depressive disorder, and anxiety, along with current orders for clozapine and duloxetine; PASRR Level I screens on 3/4/25 and 6/11/25 indicated a positive Level I and no status change, stated that the resident had a PASRR condition of serious mental illness, and said the facility should mark yes for A1500 and check the PASRR condition in A1510, yet the 10/9/25 comprehensive MDS coded A1500 as No. During interview, the SSD stated she submitted PASRR screens to Maximus but did not enter PASRR information into the MDS assessments, and the administrator stated the RN/MDS coordinator was responsible for coding PASRR information and expected the MDS assessments to be coded accurately. The facility policy stated that persons completing any portion of the MDS must sign attesting to its accuracy and that the Assessment Coordinator is responsible for transmitting encoded, accurate, and complete MDS data to CMS.
Food Safety and Hand Hygiene Failures During Meal Service
Penalty
Summary
Food was not handled and served in accordance with professional standards during meal preparation and service. During an evening meal service, resident drinks were pre-poured and stored on resident trays on an open-sided cart. A dietary assistant measured milk at 53.6 degrees F, and the dietary manager stated milk was supposed to remain between 36 and 40 degrees F. The dietary manager directed that the milk be discarded and replaced. During lunch service, pre-poured cold drinks were again removed from the refrigerator, placed on resident trays, and stored on an open-sided cart in the kitchen. Staff also failed to follow handwashing, glove use, and bare-hand contact requirements while preparing and serving food. A dietary assistant handled dirty linens with bare hands and then used those same bare hands to handle glasses, pour milk, and place the glasses on resident trays. A cook put on gloves without washing hands, handled pureed food, removed gloves without washing hands, handled refrigerated food with bare hands, and later put on gloves again without washing hands. Another cook handled cake with bare hands after touching the cake topping and then washed her hands. A dietary assistant prepared salads and sandwich meat with gloved hands, handled dirty dishes, removed gloves without washing hands, and then handled food and kitchen surfaces with unwashed bare hands. Temperature monitoring of food served to residents was incomplete and food was served at temperatures below the facility’s stated standards. One cook checked some foods on the steam table but did not check fries under the heat lamp or chicken in the warmer. Chicken pieces were found at 130 degrees F after some had already been plated for a resident, and the cook then returned the chicken to the oven. Another cook measured milk at 50 degrees F during lunch service and discarded it. The dietary manager stated staff were expected to check cooking and holding temperatures, that only cooking temperatures were documented, and that she could not be sure holding temperatures were safe if they were not documented.
Infection Control Practices Not Followed During Resident Care
Penalty
Summary
The provider failed to ensure infection control practices were followed during resident care, including cleaning mechanical lifts and slings, performing hand hygiene, and using PPE for residents on enhanced barrier precautions (EBP). During observation, a cloth sling was draped over a sit-to-stand mechanical lift in the hallway, no disinfectant wipes were available at the lift, and CNAs used the same sling and lift to transfer two residents without cleaning the equipment afterward. One sling strap was dragged on the floor before being used for another resident, and the lift was left in the hallway without being disinfected. Staff also did not perform hand hygiene after the transfers or before providing additional resident care and food assistance. Multiple CNAs were observed assisting residents with eating and other cares without completing hand hygiene at required times. One CNA assisted several residents with snacks and drinks after removing gloves, wiping her nose, and handling a soiled glove without washing her hands. Another CNA removed gloves while assisting a resident with yogurt and continued helping residents eat without hand hygiene. A CNA was also observed touching a wheelchair foot pedal, removing gloves without hand hygiene, and then entering another resident’s room to prepare that resident for transfer. Staff also failed to follow EBP precautions for residents with catheters, wounds, or other conditions requiring barrier precautions. Two CNAs entered a resident’s room with EBP signage and available gowns and gloves but did not don gowns before using a manual full body lift to transfer the resident. In another room, two CNAs transferred a resident on EBP who had a urinary catheter and an open skin wound; one CNA performed perineal care and then continued with the same gloves to adjust the catheter tubing and bag, assist with dressing, and complete the transfer, while the other CNA left the room wearing gown and gloves and later handled laundry room keys before washing hands. The record review identified one resident on EBP due to a recurring elbow infection and MRSA, and another resident on EBP due to a catheter, pressure ulcer, and feeding tube. Interviews with staff and the DON confirmed expectations for hand hygiene, cleaning lifts between uses, and wearing gown and gloves for direct care and transfers for residents on EBP.
Failure to Honor Resident DNR Status During CPR
Penalty
Summary
Staff failed to follow a resident's documented Do Not Resuscitate (DNR) code status when the resident was found unresponsive with no pulse or respirations. Despite the presence of an advance directive and an active physician's order indicating DNR/DNI status, staff initiated and continued cardiopulmonary resuscitation (CPR) for approximately 20 minutes before the Director of Nursing (DON) arrived and instructed them to stop after verifying the resident's code status. The nurses involved reported that they began CPR, checked the code status, but continued resuscitation efforts under the belief that once CPR was started, it should not be stopped until emergency medical services arrived. The resident's code status was documented in both the electronic medical record (EMR) and on hall sheets that staff were expected to carry. Interviews revealed that while some staff understood the need to verify code status before initiating CPR, others did not follow this protocol during the incident. Additionally, a certified nursing assistant (CNA) reported that orientation training did not specifically address code status procedures, and the DON was unable to provide signed documentation verifying which staff attended a post-incident educational meeting on advance directives and code statuses. Facility policies required staff to provide basic life support, including CPR, unless a valid DNR order was in place, and indicated that code status information was accessible in the EMR and hall sheets. However, there was no evidence of ongoing auditing or monitoring to ensure staff awareness and adherence to these protocols at the time of the incident. The failure to verify and honor the resident's DNR status before and during resuscitation efforts constituted the deficiency.
Failure to Prevent and Respond to Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a known history of sexually inappropriate behavior was not adequately supervised, resulting in unsolicited sexual contact with another resident. The incident took place in a hallway and common areas where both residents, who ambulated independently via wheelchairs, were left unmonitored by staff. Despite care plan interventions and hall sheets indicating that both residents required 1:1 supervision within arm's length at all times, staff failed to maintain the required level of monitoring. Camera footage confirmed that staff, including a CNA and an LPN, were not present or did not intervene during multiple interactions, allowing the resident to touch the other resident's private area without consent. The resident who committed the inappropriate act had a documented history of dementia, altered mental status, anxiety, and previous sexually inappropriate behaviors, necessitating close supervision in common areas. The other resident had diagnoses including dementia, anxiety, psychotic disturbance, and mood disturbance, with significant communication limitations. Despite these known risks, staff did not follow the supervision protocols outlined in the care plans and staff meeting notes, which specifically required staff to be within arm's length of the resident with a history of inappropriate behavior. Additionally, after the incident, there was a lack of immediate assessment and documentation regarding the well-being of the resident who was touched. The LPN did not complete an assessment or incident report at the time, and the Director of Nursing did not initiate an internal investigation until several days after becoming aware of the incident. The facility's abuse prohibition policy required prompt reporting, assessment, and investigation of suspected abuse, but these procedures were not followed in this case.
Failure to Assess Resident After Unsolicited Physical Contact
Penalty
Summary
A deficiency occurred when staff failed to complete a resident assessment for the physical and emotional well-being of a resident who experienced unsolicited touching by another resident. The incident involved two residents, both with dementia and other cognitive impairments, who were independently ambulating in wheelchairs in a hallway unmonitored by staff. One resident approached the other, rubbed her leg, and later touched her private area without consent. Staff were not present to intervene during the initial incident, and when a CNA did encounter the residents, she did not immediately separate them or stop the inappropriate behavior. The nurse on duty was not aware of the proximity of the residents and did not witness the incident directly. Following the incident, the nurse did not conduct a timely assessment of the affected resident's physical or emotional state. Although the nurse documented a progress note based on secondhand reports from staff and housekeeping, she did not complete an incident report or perform an immediate assessment. The only assessment of the resident's vital signs occurred two days later, after the DON returned and inquired about the event. There was no documentation of a thorough evaluation of the resident's well-being or any follow-up notes addressing the incident's impact on her. The facility's policies required close monitoring of the resident with a history of sexually inappropriate behavior, including 1:1 supervision within arm's length in common areas. Documentation and staff meeting notes reiterated this requirement. However, video footage and staff interviews confirmed that this supervision was not maintained at the time of the incident. Additionally, the facility lacked a clear policy for incident reporting, relying instead on an electronic documentation system with dropdown options, which did not ensure that all necessary steps, such as resident assessment, were completed after such incidents.
Failure to Use Required Safety Straps During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident was transferred using a sit-to-stand mechanical lift without the required safety straps, contrary to the manufacturer's instructions. The incident took place when the resident's right arm gave out during the transfer, causing the waist belt to pop off and resulting in the resident being lowered to the floor. The safety straps on the lift were not used on the resident's waist or legs during the transfer, and this omission was confirmed by both the facility's internal investigation and staff interviews. The resident initially refused medical treatment but later agreed to an x-ray, which showed no injury. The resident involved had a history of stroke resulting in no use of his left arm and leg, but was able to bear weight with a brace on his left leg. Documentation in the electronic medical record (EMR) indicated that the resident had previously refused to use the chest or leg straps during transfers, despite being educated on their necessity for safety. Staff interviews revealed that some staff had not experienced refusals from the resident, while others confirmed his refusals and described him as particular and sometimes verbally abusive regarding his care. The care plan and EMR lacked clear documentation about the resident's fall risk, transfer method, or history of falls. The facility relied on a working care plan and a hall sheet for daily care instructions, but the EMR care plan did not include specific transfer information. The manufacturer's instructions for the lift required the safety strap to be securely fastened around the patient's torso, and the use of a shin strap if necessary. The failure to follow these instructions and ensure the use of safety straps during the transfer directly led to the incident.
Resident Ingests Chemical Due to Improper Storage
Penalty
Summary
The deficiency involved a resident with severe cognitive impairment who ingested a Santimine tablet, a sanitizing chemical, due to improper storage. The resident, who had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment, was observed with a blue coloration in his mouth, which was identified as a Santimine tablet. The resident was on close 1:1 monitoring due to his cognitive condition and behavioral disturbances, yet he managed to access the tablets from an unlocked drawer in the Challenging Behaviors Unit (CBU). The incident occurred when two CNAs were present in the CBU, but one was assisting another resident in the bathroom, leaving the resident unsupervised momentarily. The Santimine tablets were supposed to be locked up, but they were found in an unlocked drawer behind resident clothing protectors. The drawer lock had been broken for some time, and the tablets were left unsecured by a CNA who had used them to make a cleaning solution earlier. This lapse in securing hazardous materials led to the resident's access to the tablets. Interviews with staff revealed that the Santimine tablets were not properly secured, and the staff were aware that they should have been locked. The facility's policy on hazardous materials required that such items be stored under lock and key to prevent access by residents. The failure to adhere to this policy and ensure the safety of the resident resulted in the ingestion incident, highlighting a significant lapse in supervision and storage of hazardous materials.
Failure to Provide Adequate Dining Assistance for TBI Resident
Penalty
Summary
The provider failed to ensure that dining assistance and nutritional needs were adequately care planned and implemented for a resident with a traumatic brain injury (TBI). The resident, who resided in the TBI unit, exhibited behavioral problems such as refusing care, medications, and meals. It was reported that if residents requiring assistance did not come out of their rooms, they were not allowed to have meal trays in their rooms. This led to the resident missing evening meals for three consecutive nights. Observations and interviews revealed that the resident was dependent on his spouse for eating assistance, and there was a lack of specific training for CNAs working in the TBI unit. The resident's care plan lacked specific instructions on the amount of eating assistance needed and did not indicate if he could eat in his room. The resident's electronic medical record showed inconsistent documentation of meal and snack intake, with several instances of the resident refusing evening meals without documented reasons or offers of alternative meals or snacks. The facility's policy required documentation of meals three times per day and as needed, but this was not consistently followed. The director of nursing confirmed that there was no specific training for CNAs in the TBI unit and that it was expected for staff to assist the resident with eating in his room if necessary. The facility's Resident Right-Nursing Home booklet emphasized the requirement to provide services to maintain the highest practicable well-being of each resident, which was not adhered to in this case.
Neglect of Residents in TBI Unit Due to Inadequate Care by LPN
Penalty
Summary
The report details a significant deficiency involving neglect of residents in a Traumatic Brain Injury (TBI) unit at a long-term care facility. Six out of eight sampled residents were not provided with necessary repositioning or toileting assistance as outlined in their care plans. The neglect was primarily attributed to a Licensed Practical Nurse (LPN) who failed to perform these duties during a night shift. The residents involved had severe cognitive impairments and required assistance with all activities of daily living, including toileting every two hours. However, the LPN did not provide the necessary care, leaving residents in soiled clothing and bedding. The deficiency was discovered following a complaint to the South Dakota Department of Health, which led to a review of video footage, interviews, and medical records. The footage revealed that the LPN spent significant periods at a desk rather than attending to the residents' needs. Interviews with staff indicated that the LPN was not adequately trained to perform Certified Nursing Assistant (CNA) tasks, and there was a lack of communication and coordination among staff regarding the care needs of the residents. The residents affected by this neglect had complex medical conditions, including traumatic brain injuries, dementia, and paralysis, which made them highly dependent on staff for their care. The failure to provide timely and appropriate care resulted in residents being left in uncomfortable and potentially harmful conditions, such as being cold, covered in feces, and soaked in urine. The facility's policies on neglect were not adhered to, as the staff did not provide the necessary goods and services to prevent physical harm and emotional distress to the residents.
Neglect in TBI Unit: Residents Not Provided Care as Directed
Penalty
Summary
The provider failed to ensure that eight residents in the Traumatic Brain Injury (TBI) unit received care as directed by their care plans. A complaint was filed with the South Dakota Department of Health, highlighting neglect in the TBI unit. Specifically, one resident was found in the same clothes from the previous day, curled up on the floor without a blanket, cold to the touch, and covered in feces. The resident's bed was untouched from the previous day. Other residents were noted to be incontinent of bowel and bladder, yet there was no evidence of care being provided to address these needs. The review of video footage from the TBI unit revealed that staff, including LPNs and CNAs, were present but did not provide the necessary care to the residents. The footage showed staff spending significant time at a desk or performing tasks unrelated to direct resident care. For example, one LPN was observed sitting at a desk for extended periods, and another staff member was seen entering and exiting rooms without providing care. The lack of an ADL policy and the absence of documented care activities further contributed to the deficiency, as staff failed to anticipate and meet the residents' needs, despite their cognitive impairments and dependency on staff for daily living activities.
Inaccurate Elopement Risk Evaluations
Penalty
Summary
The facility failed to ensure accurate elopement risk evaluations for 15 out of 22 residents, including a resident who had previously eloped. This resident, who had diagnoses of macular degeneration and dementia with behavioral disturbances, was able to leave the building undetected due to a malfunctioning door alarm. Despite having a Brief Interview for Mental Status (BIMS) score indicating moderate impairment, the resident's elopement risk evaluations were inaccurately marked as not at risk, even after a previous elopement incident. The facility's policy required elopement risk evaluations to be completed upon admission and after any elopement event, but this was not adhered to. Interviews with staff revealed that the elopement risk was not updated in the resident's care plan, and the incident was not initially recognized as an elopement or a reportable event. The facility's transition to a new electronic medical record system may have contributed to the oversight, as the resident's care plan and risk evaluations were not properly updated to reflect the elopement risk.
Resident Subjected to Unwarranted Physical Restraint by CNA
Penalty
Summary
The report details a deficiency involving a cognitively impaired resident who was subjected to physical restraint by an agency CNA, which was not required for medical treatment. The incident occurred after the resident returned from the hospital, where she had been treated for symptoms including slurred speech and weakness. Upon her return, the resident was restless and attempted to stand up multiple times, leading the CNA to physically restrain her by holding her arms down and pressing her chin into the resident's scalp. The incident was not immediately reported or documented in the resident's medical records, and it was only discovered after a review of video footage several days later. The footage showed the CNA restraining the resident for a total of 20 minutes over a 90-minute period. During this time, other staff members were present in the unit but did not witness or report the restraint. The facility's Director of Nursing and Administrator confirmed the occurrence of abuse after reviewing the footage. The resident involved had a history of unspecified dementia, bipolar disorder, and Alzheimer's disease, and was residing in the facility's challenging behavior unit. Despite the incident, the resident did not recall the event or any mistreatment by staff. The facility's policy prohibits the use of physical restraints unless necessary for medical symptoms, highlighting a failure in adherence to this policy in the reported incident.
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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 Irene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wakonda Heritage Manor | 6 mi | ★★★★★ | 5 | 0 |
| Pioneer Memorial Nursing Home | 7.3 mi | ★★★★★ | 0 | 0 |
| Centerville Care And Rehab Center Inc | 10.5 mi | ★★★★★ | 0 | 0 |
| Sd Human Services Center - Geriatric Program | 16.9 mi | ★★★★★ | 0 | 0 |
| Bethesda Of Beresford | 18.9 mi | ★★★★★ | 8 | 0 |
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