Avera Bormann Manor

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint the review of observations, interviews, electronic medication records and policy review revealed the facility failed to allow resident their right of self-determination.* 3 of 36 residents were not allowed to eat until the end of the meal service per a nurses request (6,8,9).* 1 additional food request was not granted* Call light times were reviewed due to excess wait times. 4 of 11 residents (1,2,3,4) had negative outcomes from wait times.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint report review, observations, interviews, and policy review, the provider failed to ensure physician orders were received for self-administration of medications for two of seven observed sampled residents (2 and 3) who self-administered medications. Findings Include:1. Review of the12/2/2025 SD DOH complaint intake revealed:*Medications were given in the dining room.*Staff were available to assist residents to eat each meal.*Blood sugars were being taken at appropriate time and locations as per resident doctors' orders and care plan preferences.*Unwitnessed and unreported falls.*Licensed staff were working in the facility within their scope of practice.*Hygiene with nails, hair, bathing and shaving were completed. 2. Observation on 2/3/26 at 8:20 a.m. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake review, observations, interviews, record review, electronic medication records and policy review, the provider failed to ensure the staff followed professional standards regarding the safe transfer of one of one sampled resident (5) who was transferred with a total body mechanical lift by the certified nursing assistant (CNA) K and registered nurse (RN) F after he fell and had a suspected hip injury. Findings Include:1. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, interview, and policy review the provider failed to ensure the safety of one of one sampled resident (1) who fell from a full body mechanical lift (a lift and sling used to lift a person's body) while being transferred from his bed to his wheelchair by certified nursing assistant (CNA) I and CNA J which required him to go to the emergency room for evaluation.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to:Ensure a controlled medication (medications at risk for abuse and addiction) was securely stored by one of one registered nurse (RN) E who placed a controlled medication (Norco) in an unsecured cabinet in the north hallway and did not administer that medication to one of one sampled resident (4) as ordered by the resident's physician. Ensure controlled medication patches were handled and securely stored for destruction according to the provider's policy.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to assess for safe usage of a lift chair for one of one sampled resident (1) who had an unwitnessed fall and required hospitalization for injuries acquired from the fall and pain management. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI) review, record review, observation, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell from a mechanical bath chair lift, suffered injuries that required emergency room treatment, hospitalization, and subsequently died when one of one certified nursing assistant (CNA) (C) failed to ensure a safety belt was used. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. On [DATE] at 9:00 a.m. Immediate Jeopardy (IJ) was identified for resident safety related to a facility-reported incident that occurred on [DATE] when a resident (1) fell from a bath chair, received serious injuries, and later died. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to implement the following for one of one sampled resident (17): *Assess for the use of an audible chair alarm. *Document the use of the chair alarm. *Reassess for the continued use of the chair alarm. *Ensure the audible chair alarm was not causing harm.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure one of one sampled resident (13) with hand contractures had a call light she was able to use and was within her reach.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure two certified nursing assistants (H and K): *Applied a mechanical stand aide sling to sampled resident (22) prior to use. *Transferred a sampled resident (22) safely from the bathroom to a specialized wheelchair. *Received documented training for the use of a mechanical stand aide and resident transfers using a specialized wheelchair (Broda chair).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure current infection control policies for hand hygiene and mechanical lift disinfection were followed by two of five staff observed (certified nursing assistant (CNA) H and K).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and observation, the provider failed to ensure the safety of one of one sampled resident (47) who eloped from the facility (left without staff's knowledge) and failed to report the elopement within the required timeframe. Failure to ensure safety could have led to resident injury had he not been found. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on review of the South Dakota Department of Health (SD DOH) online report, observation, record review, interview, and policy review, the provider failed to ensure one of three sampled residents (20) received appropriate care to prevent a burn from a warm pack. 1. Review of the SD DOH online report revealed the following: *On 1/20/24 restorative aide F applied a warm pack on the back of resident 20's neck. -The warm pack was a heated wet hand towel wrapped in Chux (disposable waterproof-under pad). -Resident 20's cognition score was a 4. Observation and interview on 1/30/24 at 12:22 p.m. resident 22 in his room revealed: *He was seated in a Broda [a specialized wheelchair] chair. *He made no eye contact, and was unable to respond coherently to questions. Review of resident 20's electronic medical record revealed his: [...]

Inspectors wroteBased on a review of the South Dakota Department of Health (SD DOH) online report, interview, and policy review, the provider failed to ensure one of one sampled restorative aide (F) provided appropriate care to prevent a burn on one of one sampled resident (20) from a warm pack. 1. Review of the SD DOH online report revealed the following: *On 1/20/24 restorative aide F applied a warm pack on the back of resident 20's neck. -The warm pack was a heated wet hand towel wrapped in Chux (disposable waterproof under pad). Interview on 1/30/24 at 10:44 a.m. with restorative aide (RA) F regarding the above-referenced report revealed: *She had started placing warm packs on residents' necks before completing their restorative nursing care to help loosen the neck muscles. -She had no training in the use of warm packs. [...]

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the privacy and confidentiality of resident electronic health records had been maintained by three of three staff (registered nurse (RN) D, RN E, and certified nurse assistant/medication aide (CNA/MA) F) during medication administration.