Avera Mother Joseph Manor Retirement Community

In the surveyor’s words

From the most serious findings on record at Avera Mother Joseph Manor Retirement Community, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 28, 2024

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell from his wheelchair while being pushed by facility staff. Failure to use wheelchair pedals may have contributed to resident 1's fall. This citation is considered past noncompliance based on the corrective actions the provider implemented immediately after the incident. Findings include: 1. Review of the provider's 7/26/24 SD DOH FRI report revealed: *On 7/26/24, occupational therapy assistant (OTA) C was wheeling the resident back to his room. The resident was holding his feet off the floor; wheelchair pedals were not attached to wheelchair. […]

• Actual harm, isolatedF684Mar 23, 2023

  Based on observation, interview, record review, and policy review, the provider failed to: *Ensure environmental precautions were in place to prevent harm to one of one sampled resident (37) who received a burn to her left ankle from a heat register in her room after her bed had been moved. *Implement timely and appropriate bowel management interventions for one of one sampled resident (128) who had been receiving hospice services. Findings include: 1. Observation on 3/21/23 at 8:09 a.m. and again at 10:08 a.m. of resident 37 revealed: *She was lying in bed under the blankets and appeared to be sleeping soundly. *The bed was in the lowest position and a fall mat was on the floor in front of the bed. *She had a full body pillow positioned beside her on the non-wall side. […]

• Actual harm, isolatedF686Mar 23, 2023

  Based on observation, interview, record review, and policy review, the provider failed to ensure ongoing and timely skin assessments were conducted and documented by a licensed nurse prior to the development of pressure ulcers for two of two sampled residents (20, and 58). Findings include: 1. Observation and interview on 3/21/23 at 10:38 a.m. with resident 20 in his room revealed he: *Was sitting in a wheelchair on a pressure relieving cushion. There was a pressure relieving cushion in his recliner and a pressure reduction mattress on his bed. *Had a colostomy, was able to empty the colostomy bag independently and the nurse changed the appliance every five days. *Received a shower with staff assistance once a week. […]

• No harm, potential for more than minimal, widespreadF732Dec 17, 2025

  Based on observation, document review, and interview, the provider failed to ensure the posted nurse staffing information included the actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants per shift, and that the form was posted daily.Findings include:1. Observation on 10/2/25 at 10:00 a.m. of the provider's nursing services staff posting revealed the number of nursing staff working was listed, but not the number of hours they worked was not included.2. Interview on 10/2/25 at 11:12 a.m. […]

• No harm, potential for more than minimal, widespreadF812Dec 17, 2025

  Based on observation, document review, interview, and policy review, the provider failed to:*Ensure appropriate hand hygiene was performed by six dietary staff (K, T, U, BB, and CC) to meet professional food cleanliness standards.*Maintain three of three dishwashers and three of three sanitation solution containers in a manner that met professional food service sanitation standards.Findings include:1. Interview on 9/29/25 at 4:32 p.m. with resident 67 revealed she:*Preferred to eat her meals in her room.*Stated her food was often cold when she received it in her room.*Told the kitchen staff that her food was often cold, but no one had followed up with her regarding that concern, and her food continued to be delivered to her cold.2. […]