Avera Sister James Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 5, 2026

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the staff used assistive safety devices for one of one resident (1) who fell, suffered a broken nose, and required emergency room treatment, while ambulating to a meal when one of one certified medication aide (E) failed to use a gait belt (a waist strap gripped as support for safe mobility and transfers) while assisting resident 1 with ambulating (walking).Findings include: 1. […]

• No harm, potential for more than minimal, patternF641May 14, 2026

  Based on record review, interview and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, the provider failed to ensure four of six sampled residents' (3, 34, 107, and 151) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop and individualized care plan to manage the resident's care needs) assessments were accurately coded for the areas of diagnosis, Pre-admission Screening and Resident Review (PASRR) or dialysis. Findings include:1. Review of resident 34's EMR revealed he was admitted to the facility on [DATE]. His 2/24/26 BIMS assessment score was 15 which indicated his cognition was intact. […]

• No harm, potential for more than minimal, patternF812May 14, 2026

  Based on observation, interview, and document review, the provider failed to follow food safety standards to ensure that equipment in food service and preparation areas was maintained in a sanitary condition for two of six pantry dishwashers, one of five wall-mounted fans, and one of fifteen handwashing sinks. This deficient practice had the potential to affect the safety of food served to residents. Findings include:1. Observation on 5/14/26 at 7:58 a.m. in the Country neighborhood pantry revealed that there was a thick layer of biofilm (a sticky film with germs) and food particle buildup on the inner surface of the dishwasher doors, which could result in dishes not being properly cleaned and sanitized, which could place residents at risk for foodborne illness.Across the room from the… […]

• No harm, potential for more than minimal, patternF926Jan 8, 2025

  Based on observation, interview, record review, and policy review, the provider failed to implement their tobaco free campus policy for three of three sampled residents (66, 115, and 144) who smoked on the provider's property. Findings include: 1. Observation on 1/7/24 at 8:29 a.m. of resident 144 revealed: *She was seated in a wheelchair with a coat on. *She used the side exit door on the Chalkstone Drive neighborhood to go out to smoke. *The exit door had been propped open and a staff member stood there and monitored her while she smoked a cigarette. 2. Observation and interview on 1/7/25 at 9:56 a.m. with resident 66 in his room revealed: *He smoked and kept his smoking supplies in his room. *The staff would let him out when he wanted to go smoke. 3. […]

• No harm, potential for more than minimal, patternF676Jan 24, 2024

  Based on a complaint, record review, observation, and interview, the provider failed to ensure six of eight sampled residents (1, 2, 3, 4, 5, and 6) had received regular scheduled bathing. Findings include: 1. Review of the South Dakota online report received on 1/10/24 revealed: *The complainant reported that on Sunday 1/7/24, the overnight shift was short-staffed and they had a concern about the residents safety. *The complainant was concerned that the day shift had also been short-staffed and often residents were not getting their scheduled baths, stating residents are going 8 or 9 days without a bath. *The provider had been short-staffed on and off for a while. […]