Sun Dial Manor

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported intake (FRI) review, interview, record review, and policy review, the provider failed to ensure an investigation was completed and documented for four of five resident elopements (leaving the facility without staff knowledge) after one of one resident (2) eloped on 11/22/25, 11/29/25, 12/4/25, and 1/1/26.

Inspectors wroteBased on policy review, observation, record review, and interview, the provider failed to ensure one of one low-temperature dishwasher: *Wash and rinse cycle temperatures were monitored and documented at each meal according to their policy. *Chlorine sanitizer concentration level was monitored and documented at least once per shift according to accepted food safety standards of practice.

Inspectors wroteBased on record review and interview, the provider failed to ensure the proper Medicare notices were filled out completely and were in the required format for three of three sampled residents (1, 6, and 75) prior to their discharge from Medicare Part A skilled services.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure four of fourteen sampled residents (3, 6, 11, and 20) with bed rails determined to not be restraints were accurately coded on the Minimum Data Set (MDS) assessments.

Inspectors wroteBased on interview, record review, observation, and policy review, the provider failed to ensure baseline care plans had been completed and a written summary of the baseline care plans had been provided to the resident or their representative for four of four recently admitted sampled residents (3, 19, 20, and 175) within 48 hours of their admission to the facility.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure: *A bed rail was properly installed for one of one sampled resident (20). *Entrapment risk was assessed for two of two sampled residents (11 and 20) with bed rails. *There was documented resident-specific risk versus benefits education provided for the informed consent for use of bed rails for two of two sampled residents (11 and 20). *Alternatives were attempted and documented prior to the installation of bed rails for two of two sampled residents (11 and 20). *There was routine maintenance of the bed rails for two of two sampled residents (11 and 20).

Inspectors wrote2. Interview and observation on 5/19/25 at 9:22 a.m. in resident 5's room revealed: *She had a refrigerator in her room. *There was no temperature log with the refrigerator temperatures posted on or near the refrigerator for May 2025. *There was a thermometer on the inside of the refrigerator door that read 33° Fahrenheit (F). *She stated the refrigerator temperatures were not checked daily by staff. *Her daughter would check the refrigerator every few days when she visited. *The resident would keep her drinks and snacks in the refrigerator, so they were available to her when she wanted them. 3. Observation on 5/20/25 at 10:42 a.m. in resident 5's room of her refrigerator revealed: *The temperature read 32°F. *The top shelf contained the following items: -A 64-ounce plastic bottle of opened prune juice with no open date. -Four 4-ounce opened vanilla pudding cups with no open dates. [...]

Inspectors wroteBased on observation, interview, and policy review, the provider failed to follow appropriate infection control practices to ensure: *Shared sit-to-stand mechanical lift slings used for three of three residents who required the sit-to-stand mechanical lift for transfers was properly disinfected between resident use. *Personal protective equipment (PPE) was available in one of one soiled utility rooms to prevent infections and cross-contamination when using the hopper to rinse soiled linens. 1. Observation on 5/19/25 at 8:50 a.m. of the soiled utility room revealed: *There was a hopper (a flushing device used to rinse items and linens soiled with bodily fluids) without a barrier to prevent splash contamination to staff who cleaned contaminated linen. [...]

Inspectors wroteBased on record review, interview, and policy review, the provider failed to follow their policy and facility assessment to ensure an effective training program for one of two contracted (agency) staff (O).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (1) observed self-administering a nebulizer (device that converts liquid medication into an inhaled mist) treatment in her room, was assessed for the ability to safely self-administer medications, and had a physician's order to self-administer medications according to the provider's policy.

Inspectors wroteBased on personnel file review, interview, and policy review, the provider failed to ensure resident safety by employing one of one certified nursing assistant (CNA) M with a known documented history of abuse as prohibited in a provider's policy.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) submitted complaint report, record review, observation, interview, and policy review the provider failed to ensure: *One of one sampled resident (3) with a suprapubic catheter was place on enhanced barrier precautions (EBP). *Two of two sampled residents (1 and 2) with multi-drug resistant (MDRO) infections were placed on contact precautions.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, and record review, the provider failed to ensure the safety of one of one sampled resident (1) who fell out of an electric lift chair and received a laceration to her left temple that required sutures.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), SD DOH complaint intake report review, interview, observation, record review, and policy review, the provider failed to ensure: *Six of twelve severely cognitively impaired sampled residents (1, 2, 3, 4, 5, 6) who had lift recliner chairs in their rooms had been assessed for appropriate use and as potential restraints. * One of three severely cognitively impaired sampled residents (1) who used a specialty wheelchair had been assessed for the appropriate use to determine if it was a potential physical restraint.

Inspectors wroteBased on interview, and policy review, the provider failed to ensure all licensed nursing staff [registered nurses (RNs) and licensed practical nurses (LPNs)], unlicensed assistive personnel (UAPs), and certified nursing assistants (CNAs) completed competency evaluations prior to working with residents, and annually.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the activity coordinator had the ability to develop, implement, supervise, and evaluate a one-to-one activities program for four of four sampled residents (10, 12, 13 and 19) at risk for social isolation.

Inspectors wroteBased on interview, staff schedule review, and payroll record review, the provider failed to ensure a registered nurse (RN) was scheduled for eight consecutive hours for multiple shifts from April 2023 through August 2023.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to have a secure system for storing medications that were awaiting destruction in one of one medication storage cupboard.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure a code status (individual desire to resuscitated Full Code with cardiopulmonary (CPR) versus not resuscitated if their heart stopped Do no resuscitate (DNR)) was designated by the resident and/or their representative for two of two sampled residents (10 and 20).

Inspectors wroteBased on South Dakota Department of Health (SDDOH) report review, record review and interview, the provider failed to ensure one of one sampled resident (8) had received appropriate and necessary care and treatment for nine days after a witnessed fall in her bathroom.

Inspectors wroteBased on interview, record review, and policy review the provider failed to ensure one of one sampled resident (8) who had a fall with a fracture and transported to an acute care facility was thoroughly investigated and reported to the South Dakota Department of Health (SDDOH).