Avera Prince of Peace

In the surveyor’s words

From the most serious findings on record at Avera Prince of Peace, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 3, 2025

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the facility failed to ensure the safe use of a mechanical lift (a mechanical lift and sling used to lift a person's full body) by not having assessed the resident for the appropriate lift sling size to have used for one of one sampled resident (2) who fell from the sling and sustained multiple fractures. 1.Review of the provider's 5/15/25 SD DOH FRI revealed:*Certified nursing assistant (CNA) E and CNA F were transferring resident 2 from his wheelchair to his bed while using a full-body mechanical lift.*Resident 2 fell forward out of the lift sling and landed on his face on the floor.*He was bleeding from his chin and mouth and was transferred to… […]

• No harm, potential for more than minimal, patternF565Aug 21, 2025

  Based on resident council meeting, resident council meeting minutes review, and interview, the provider failed to provide resource information and prompt resolution to residents' requests and concerns voiced in resident council meetings that were to the residents' satisfaction. Findings include:1. A resident council meeting on 8/21/25 at 11:15 a.m. was attended by twelve nursing home residents and revealed:*No residents in attendance were able to name the facility grievance official. *One resident stated she would talk to a nurse if she had a grievance.*Ten of the twelve residents expressed concern and fear of turning on call lights at night due to receiving negative responses from the certified nursing assistants (CNAs). […]

• No harm, potential for more than minimal, patternF583Aug 21, 2025

  Based on observation, interview, and policy review, the provider failed to ensure resident personal and medical records remained secure and confidential in four of six observed resident neighborhoods (Bluegrass Way, Platinum Ridge, Boulder Creek, and Arrowhead Trail).Findings include: 1. Observation on 8/19/25 at 8:11 a.m. in the Boulder Creek hallway outside resident 129’s room revealed: *Resident 129’s door to her room was closed. *There was a computer on a rolling stand outside resident 129’s room. *The computer screen was open with residents' medical information visible on the screen. *The computer screen indicated certified medication aide (CMA) M was logged into the computer. *There were no staff within eyesight of that computer. […]

• No harm, potential for more than minimal, patternF600Aug 21, 2025

  Based on resident council meeting response, subsequent individual interviews, resident complaint/grievance reports, and policy review the provider failed to ensure residents were kept free from neglect as it related to ten of twelve residents who attended resident council on 8/21/25, in addition to 11 of 11 sampled residents (2, 44, 51, 61, 66, 73, 77, 79, 91, 108, and 126) who communicated complaints of long staff response times to call lights, which left the residents feeling humiliated, fearful, and in pain.Findings include: 1. A resident council meeting on 8/21/25 at 11:15 a.m. […]

• No harm, potential for more than minimal, patternF761Aug 21, 2025

  Based on observation, interview, record review, and policy review, the provider failed to ensure: *Insulins with shortened expiration dates were dated properly for five of five random residents (27, 44, 60, 75, 76).*Medical supplies, such as glucose testing strips, sterile water, distilled water, and formula, were dated properly for seven of seven residents (4, 9, 27, 44, 63, 75, 119) in two of five observed units. *Medications were not accessible by unnecessary persons throughout the Rehab, Arrowhead Trail, Boulder Creek, Bluegrass Way, and Platinum Ridge units. *Proper medication administration for two of two residents (63 and 119) without a self-administration physician's order or safety assessment completed.Findings include:1. […]