Avera Brady Health and Rehab

In the surveyor’s words

From the most serious findings on record at Avera Brady Health and Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF655Dec 12, 2024

  Based on record review, interview, and policy review the provider failed to review with the resident, their representative, or their responsible family member and provide a written summary of the baseline care plan for five of eighteen sampled residents (2, 26, 68, 69, and 71) within 48 hours of their admission. Findings include: 1. Review of resident 26's electronic medical record (EMR) revealed: *She had been admitted on [DATE]. *Her diagnoses included acute ischemic left MCA (middle cerebral artery) stroke, with right hemiplegia (paralysis or weakness on one side of the body), aphasia (a communication disorder, dysphagia (difficulty swallowing), depression, anxiety, malnutrition, weakness, and a history of GI (gastrointestinal) bleed. […]

• No harm, potential for more than minimal, patternF684Dec 12, 2024

  Based on observation, interview, record review, and policy review the provider failed to maintain the physical, mental, and psychosocial well-being by ensuring staff promptly responded to call lights for two of eighteen sampled residents (1 and 16) who used call lights to alert staff of their assistance needs. Findings include: 1. Observation and interview on 12/10/24 at 9:51 a.m. with resident 1 in her room revealed: *She was seated in her recliner. *Her call light was within her reach. *She stated it had taken staff at least 30-60 minutes go answer her call light at times. *She said she had waited so long that she had been incontinent of bowel and bladder. 2. Observation and interview on 12/10/24 at 10:50 a.m. […]

• No harm, potential for more than minimal, isolatedF684Apr 27, 2026

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, observation, interview, document review, record review, and policy review, the provider failed to protect the resident's right to quality of care according to the resident's assessment and needs for one of one sampled resident (41) whose call system cord was not working and was on a commode (portable toilet) for one hour and fifteen minutes, which was 30 minutes longer than the resident's preference, by one of one certified nursing assistant (CNA) N who did not return to resident 41's room to check on her. That failure resulted in emotional distress for the resident, who was observed by administrator (A) as being distressed, upset, and having tears in her eyes when discussing the incident. […]

• No harm, potential for more than minimal, isolatedF812Apr 27, 2026

  Based on observation, interview, employee education review, and policy review, the provider failed to ensure standard food safety practices were followed for one of one observed cook I who did no perform hand hygiene (washing or sanitizing hands) after she dropped and picked up a butter container lid from the floor, and coughed into her right hand and drank from her personal beverage cup while preparing and serving resident meals during the lunch meal service. Findings include:1. Observation on 4/21/26 from 12:15 p.m. through 1:00 p.m., in the [NAME] kitchenette and dining room, revealed that cook I dropped the lid to the butter container onto the floor. She then picked the lid up and placed it on the counter next to an open bag of bagels. […]

• No harm, potential for more than minimal, isolatedF689Feb 26, 2026

  Based on record review, interview, observation, policy review, and manufacturer's manual review, the provider failed to ensure a safe environment for one of one sampled resident (1), who chose not to wear the whirlpool tub chair's safety belt by not educating the resident of the risks for adverse outcomes of not using the belt, to make an informed safety decision regarding the use of that safety belt. That failure put the resident at risk for falling and potential injury. Findings include:1. […]