Avera Morningside Heights Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Sep 24, 2025

  Based on interview and document review, the facility failed to ensure staff appropriately assessed, monitored, intervened, and notified the family in a timely manner after a fall for 1 of 1 resident (R1) resulting in a brain bleed and skull fracture causing serious harm and eventual death. The immediate jeopardy (IJ) began 9/15/25 at 10:23 p.m., when the facility failed to ensure staff appropriately assessed, monitored, and intervened after a fall for 1 of 1 resident (R1) who had an unwitnessed fall with visible facial bruising and facial structure abnormalities, that resulted in delayed medical examination by a physician and early treatment. […]

• Actual harm, isolatedF689Mar 24, 2026

  Based on observation, interview, and document review, the facility failed to ensure adequate supervision was provided to prevent falls for 1 of 3 residents (R2) reviewed for falls. R2 needed increased monitoring for safety due to her fall risk with one-to-one (1:1) supervision which was not provided when the nursing assistant (NA) left R2 alone to go wash their hands. R2 then fell causing harm when R2 obtained a left olecranon (elbow) fracture which needed surgery. Findings include: R2's progress note, dated 1/2/26, identified R2 admitted to the nursing home from the hospital. R2 was an assistance of two staff with an EZ Stand for transfers and was non-weight bearing (NWB) to her right upper extremity with a sling on at all times. […]

• Actual harm, isolatedF686Nov 30, 2023

  Based on observation, interview, and document review, the facility failed to identify and implement interventions to prevent new pressure ulcer (PU) development for 1 of 1 resident (R61) who was at risk for PU upon admission. This caused actual harm when the facility failed to identify interventions to prevent new PU's to R61's heels and hip. Findings include: R61's: 1) 7/6/23, admission Minimum Data Set (MDS) assessment identified R61's cognition was severely impaired. R61 was dependent on staff for bed mobility, transfers, and toileting. R61 was identified as at risk for pressure ulcer (PU) development with no pressure ulcers present at that time. R61 had no venous or arterial ulcers, however, did have a skin tear. […]

• No harm, potential for more than minimal, widespreadF868Dec 3, 2025

  Based on interview and document review, the facility failed to ensure its Quality Assurance Performance Improvement (QAPI) program provided supervision for 1 of 1 infection preventionist (IP), to identify a thorough infection control surveillance program included surveillance of all employee illness. QAPI also failed to ensure employee surveillance was appropriately delegated to personnel in employee health (EH) who were not certified in infection control. This had the potential to affect all 74 residents. Refer to F880 and F882Findings include: Review of the current, facilities infection control surveillance for employees identified the facility utilized corporate employee health to track employee illness. […]

• No harm, potential for more than minimal, widespreadF880Dec 3, 2025

  Based on interview and document review, the facility failed to have a current, ongoing system of surveillance for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases that included all staff. This had the potential to affect all 74 residents. Refer to F882 and F868 Findings include: Review of facility infection control surveillance identified only resident illness surveillance had been completed at the facility. Interview on 12/2/25 at 4:10 p.m., with the infection preventionist (IP) identified employee's call central employee health (EH) when ill to report their symptoms, EH then provides the employee general guidelines of when they can return to work. […]