Sunset Manor Avera Health

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, and policy review, the provider failed to report a physical abuse incident to the SD DOH within the required time frame for one of one sampled resident (1), who was straddled and restrained in his bed by one of one certified nursing assistant (CNA) (G) while he provided incontinence (involuntary urine and bowel leakage) care to resident 1. Findings include: Findings include: 1. Review of the provider's 3/23/26 SD DOH FRI (a required reporting of unexpected or adverse events) report revealed that on 3/22/26 at 4:00 a.m., resident 1 was combative during morning care rounds (changing of residents who were incontinent of stool or urine). CNA G had turned the resident so he was positioned on his side, lying in his bed. That increased the resident's combative behavior, so CNA G placed a leg over the resident to straddle him. CNA G then used his thumb and put pressure on a pressure point under the resident's ear (to lock the resident's jaw) to distract the resident. This increased…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview, and facility assessment review, the provider failed to post the required nursing staffing information in a location readily visible to residents, staff, and visitors that clearly reflected actual hours worked by the nursing staff from October 2025 through December 2025 daily:*For 46 of 92 days reviewed regarding the Traumatic Brain Injury unit (TBI).*For 24 of 92 days reviewed regarding the Challenging Behavior Unit (CBU).*For 13 of 92 days reviewed regarding the main area where residents resided (The Manor). Findings include:1. Observation on 12/29/25 at 2:34 p.m. of the provider's posted nurse staffing hours for The Manor and the CBU revealed:*The information was posted on a bulletin board near the nurses' station in the Manor.*It included the date of 12/26/25 and resident census for The Manor and the CBU.*There were no registered nurse (RN) hours documented on those postings.2. Observation on 12/29/25 at 3:45 p.m. in the TBI unit revealed there were no posted nurse staffing hours.3. Observation on 12/31/25 at 9:28 a.m. of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure six of six sampled residents' (2, 6, 9, 34, 39, and 40) with a severe mental health illness Minimum Data Set, a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs, (MDS) assessments were accurately coded for the area of Pre-admission Screening and Resident Review (PASRR).Findings include: 1. Review of resident 2's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His diagnoses included bipolar (mental condition causing extreme shifts in mood, energy, and activity levels), and neurocognitive disorder (a group of conditions marked by the decline in mental function like memory, thinking, and reasoning) and psychotic disorder (a loss of contact with reality characterized by symptoms like delusions (false beliefs) and hallucinations (seeing, hearing, feeling things that are not true)). *He had a level I (1) PASRR completed on 9/5/25 for a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review, and policy review the provider failed to ensure the staff followed standard food safety practices regarding:*Monitoring the food and drink temperatures prepared and served were served to residents by cook M, P and Q and dietary assistant (DA) N on one of one evening meal services and one of one lunchtime meal services.*Handwashing and glove use by DA N and O and Cooks P and Q was followed during one of one evening meal service and one of one lunch time service in the kitchen. Findings include:1. Interview on 12/29/25 at 3:17 p.m. with resident 48 in her room revealed:*She stated the food was not prepared well.*At times the food is overcooked and at times it is cold.*She stated that there were multiple residents who did not eat their meals due to how the food was prepared and served.*She had reported her concerns to staff members but they were not the staff members who had the authority to do anything about her concerns.2. Observation on 12/29/25 at 5:23 p.m. from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed regarding: *Cleaning of mechanical lifts and slings by three of three certified nursing assistants (CNA) (W, Z, and AA) observed while transferring three of three sampled residents (9, 24, and 25).*Hand hygiene completed by five of five CNAs (W, X, Z, BB, and CC) observed when assisting three of three sampled resident (17, 24, and 50) with cares.*Hand hygiene completed by two of two CNAs (W and Y) observed assisting five of five sampled resident (1, 9, 16, 25, and 40) to eat. *Use of personal protective equipment by two of two CNAs (X and AA) while providing resident care to one of one sampled resident (24) who was on enhanced barrier precautions (EBP). Findings include: 1. Observation on 12/29/25 at 2:24 p.m. in the common area of the Challenging Behavior Unit (CBU) revealed: *There was a sling made of cloth material draped over the sit-to-stand mechanical lift (a mechanical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), record review, interview, and policy review, the provider failed to ensure staff followed a resident's documented do not resuscitate (DNR) code status wishes for one of one closed record sampled resident (52) when discovered with no pulse or respirations by staff and was then provided cardiopulmonary resuscitation (CPR) without first verifying the resident's code status. Findings include: 1. Review of the provider's [DATE] SD DOH FRI revealed:*On [DATE] at 5:20 a.m. a nurse obtained resident 52's vitals which were stable, and her blood sugar was reading high both times it was checked and then assisted resident 52 (who had agreed to go to the hospital) to the restroom.*The nurse called the on-call provider to report on resident 52's condition and to receive orders to administer insulin and Zofran (medication for nausea).*A second nurse went to resident 52's room and found her slumped over on the toilet and heard a gurgling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD OH) facility-reported incident (FRI), record review, observation, interview, and policy review, the provider failed to protect the resident's right to be free from sexual abuse by one of one sampled resident (3) who made unsolicited sexual advances towards one of one sampled resident (2). Resident 3 had a history of sexually inappropriate behavior and required close supervision while in common areas around peers. Findings include: 1. Review of the SD FRI report dated 6/9/25 revealed: *The incident occurred on 6/7/25. *Residents 2 and 3 ambulated via wheelchairs independently. *Residents 2 and 3 were in a hallway unmonitored by staff. *Resident 3 propelled himself in his wheelchair up to resident 2 and rubbed her right leg then rolled away from her. *Certified nursing assistant (CNA) J talked to residents 2 and 3 in the hallway but had not separated the residents. *Resident 3 put hand sanitizer on his hands, rolled over to resident 2 and put some of the sanitizer on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, interview, and policy review, the provider failed to complete a resident assessment for the physical and emotional well-being of one of one resident (2) who experienced unsolicited touching of her body by one of one resident (3) following alleged abuse for one of one sampled resident (2). Findings include: 1. Review of the SD FRI report dated 6/9/25 revealed: *The incident occurred on 6/7/25. *Residents 2 and 3 ambulated via wheelchairs independently. *Residents 2 and 3 were in a hallway unmonitored by staff. *Resident 3 propelled himself in his wheelchair up to resident 2 and rubbed her right leg then rolled away from her. *Certified nursing assistant (CNA) J talked to residents 2 and 3 in the hallway but had not separated the residents. *Resident 3 put hand sanitizer on his hands, rolled over to resident 2 and put some of the sanitizer on her hands, started to rub her lap, and touched her private…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interviews, record review, and lift manufacturer's instructions, the provider failed to ensure that one of one sampled resident (1) was free from accident hazards during a transfer using a sit-to-stand lift when the manufacturer's operator's instructions for the safe use of the lift had not been followed. Findings include: 1. Review of the provider's FRI submitted to SD DOH on 4/16/25 at 3:42 p.m. revealed: *Resident 1 had a fall from the sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) on 4/9/25 at 5:00 a.m., when his right arm gave out and went above his head during the transfer while using the sit-to-stand and he was lowered to the floor. *The safety straps on the sit-to-stand were not used on his waist or legs during the transfer. *After the fall, he initially complained of feeling sore in both shoulders, which had been baseline for him, but no injury was visualized and he refused medical treatment. *After several days of soreness and refusal of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on South Dakota Department of Health (SD DOH) complaint, interview, interview, record review, and policy review, the provider failed to ensure dining assistance and nutritional needs were adequately care planned and implemented for one of one resident (1) with traumatic brain injury (TBI) when he refused to leave his room for meals or refused to eat. Findings include: 1. Review of the SD DOH complaint that was filed anonymously about resident 1 on 1/6/25 revealed: *Resident resided in the traumatic brain injury (TBI) unit. *He had behavioral problems, such as: refusing cares, refusing to take his medications, refusing to come out of his room for meals, refusing to eat. *When residents who required assistance would not come out of their rooms, they were not allowed to have a meal tray in their room. *Two to three weeks prior to filing the complaint, resident 1 had gone without his evening meal for three consecutive nights due to him not coming out of his room. *Resident 1 required assistance with eating. 2. Observation on 2/11/25 at 11:45 a.m. of resident 1 while eating his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SDDOH) complaint report review, record review, policy review and interview the provider failed to ensure 15 of 22 (2, 3, 7, 8, 14, 16, 20, 23, 25, 26, 29, 33, 35, 41, 43) Elopement risk evaluations were completed accurately to ensure resident safety. Findings include: 1. Review of SDDOH complaint report revealed: *Resident 43 had eloped from the building on 7/17/24 out a door that had an alarm. *The alarm did not sound and alert staff to a resident exiting the building. *Staff observed resident 43 walking with a walker across the front lawn of the building. *They assisted him back into the building. *Nurse completed vitals and assessed him to make sure he was okay. *Staff checked all other doors in the building, making sure all other alarms were working. 2. Review of resident 43's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had diagnoses of: -Macular degeneration. -Dementia with other behavioral disturbances. *Brief interview for mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a facility-reported incident (FRI) review, observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (37) who was cognitively impaired received adequate care and monitoring to ensure she was free of physical restraints imposed for discipline or convenience and not required to treat the resident's medical symptoms that resulted in an incident of resident abuse by one of one agency staff member (H). Findings include: 1. Review of the South Dakota Department of Health (SD DOH) event report for resident 37 on 6/28/24 revealed: *She returned from the hospital on 6/28/24 at 6:35 p.m., was restless, and had tried multiple times to stand up from her chair. -She was unsteady when walking. -She was redirected to sit in her wheelchair by agency certified nursing assistant (CNA) H. -For nearly an hour and half resident [resident 37] continues to try to stand up or get out of the wheelchair and resists against [first name of agency CNA H] but is physically…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, policy review, and interview the provider failed to ensure Minimum Data Set (MDS) assessments were completed in a timely manner for five of twenty-four sampled residents (3, 7, 19, 23, and 37). Findings include: 1. Review of the (MDS) schedule for the facility provided by MDS coordinator C on 7/12/23 revealed quarterly assessments for residents 3, 7, 19, 23, and 37 were to have been completed on 6/12/23. Review of the MDS transmission results summary report provided by MDS coordinator C on 7/12/2023 revealed no quarterly assessments had been submitted in June or July for residents 3, 7, 19, 23, and 37. Review of the providers 3/2022 LTC-Assessment (MDS Policy) revealed assessments would be .completed within 14 days of the resident's admission, quarterly, annually, and within any significant change in condition. Interview on 7/12/23 at 9:47 a.m. with MDS coordinator C regarding quarterly assessments for residents 3, 7, 19, 23, and 37 revealed: *Completed MDS assessments were transmitted via Internet Quality Improvement and Evaluation System at least weekly.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.