Avera Granite Falls Care Center

In the surveyor’s words

From the most serious findings on record at Avera Granite Falls Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678May 2, 2024

  Based on interview and document review, the facility failed to follow physician orders for full code and did not initiate cardiopulmonary resuscitation (CPR) as per the residents wishes for 1 of 3 residents (R1) who wanted CPR. R1 was found without a pulse or respirations, staff did not initiate CPR and R1 expired and resulted in an immediate jeopardy (IJ). The facility implemented immediate corrective action prior to survey and IJ was issued at past noncompliance. The IJ began on [DATE], at approximately 1:00 a.m. when R1 was noted to have no respirations with a fast heart rate, and CPR was not initiated. The administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE] at 4:27 p.m. […]

• Actual harm, isolatedF689Sep 19, 2025

  Based on interview and record review the facility failed to ensure a mechanical lift sling was properly secured and free from entanglement hazards following transfer and/or prior to wheelchair transport for 1 of 3 residents (R1) which resulted in harm when R1's left leg became entangled in the strap which caused a traumatic hematoma on the leg that required hospitalization, surgical intervention, and blood transfusion. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance (PNC). Findings include:R1's quarterly [NAME] Data Set (MDS) dated [DATE] indicated R1 had moderately impaired cognition, required maximum assistance with mobility, and was dependent on staff for transfers using a wheelchair. […]

• No harm, potential for more than minimal, widespreadF880Sep 2, 2026

  Based on observation, interview, and document review, the facility failed to have a system in place to monitor resident room refrigerators for appropriate temperatures and develop a process to ensure food was dated and discarded appropriately for 9 of 9 sampled residents (R1, R8, R17, R19, R20, R21, R25, R37, and R40) with in-room refrigerators to prevent potential food-borne illness. Findings include: Observation and interview on 8/31/26 at 3:05 p.m. through 3:32 p.m. of the following residents in their rooms identified:R17 had a small refrigerator with a freezer located in her room. The fridge appeared clean and had several unopen cans of soda. […]

• No harm, potential for more than minimal, widespreadF880Sep 10, 2025

  Based on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employees would be able to return to work after an illness, dependent upon their symptoms and resolution of illness for 3 of 3 staff nursing assistant (NA)-A, NA-B, and infection preventionist (IP)-A. This had the potential to affect all 48 residents who resided at the facility. Findings include: Review of the employee illness form and log identified the following information was to be obtained:NamePosition Manager Date/time symptoms startedDates/Shifts worked 48 hours within symptoms starting or date of test if asymptomaticLast day workedDate of covid-19 test Did you have close contact with patient being within 6' for greater than 15 minutes cumulative time?Were you ever… […]

• No harm, potential for more than minimal, widespreadF882Sep 10, 2025

  Based on interview and document review, the facility failed to ensure 1 of 1 infection preventionist (IP) had appropriate training and oversight of the infection control (IC) program by management by performing current, daily cumulative infection control surveillance activities, maintain documentation of incidents, findings, and any corrective actions required, and ensure the IC program continued while the newly hired IP completed training. Findings include: Review of the employee illness form identified the following information was to be obtained:NamePosition Manager Date/time symptoms startedDates/Shifts worked 48 hours within symptoms starting or date of test if asymptomaticLast day workedDate of covid-19 test Did you have close contact with patient being within 6' for greater than 15… […]