Sunset Manor Avera Health

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, interview, and policy review the provider failed to protect the residents' right to be free from physical abuse 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review the provider failed to ensure the safety of one of one sampled resident (2) with cognitive impairment who ingested an improperly stored and secured Santimine (sanitizing chemical) tablet.

Inspectors wroteBased 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.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint review, record review, interview, video review, and policy review, the provider failed to protect six of eight sampled residents (1, 2, 3, 5, 7, and 8) from neglect by licensed practical nurse (E) who did not offer or provide repositioning or toileting assistance as directed in their plans of care.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and video review, the provider failed to ensure eight of eight sampled residents (1, 2, 3, 4, 5, 6, 7, and 8) who were dependent on staff for their care needs, received those cares as directed on their care plans.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).