Avera Sunrise Manor

In the surveyor’s words

From the most serious findings on record at Avera Sunrise Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Apr 3, 2024

  Based on interview and record review the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours a day, 7 days per week, for 2 of 168 days reviewed. This had the potential to affect all 29 resdients. Findings include: Review of the facility schedules from 10/1/23 through 3/17/24, identified there was no RN coverage on 12/10/23 and 3/3/24. Interview on 4/1/24 at 6:21 p.m., with the director of nursing (DON) identified she only has 1 full time RN at the facility other than herself and the case manager. At times the facility use the adjoining hospital's RN for coverage. The hospital RN was not physically present in the facility, and took call only. […]

• No harm, potential for more than minimal, widespreadF812Aug 3, 2023

  Based on observation, interview, and record review the facility failed to ensure frozen raw meat and cooked meat were thawed in separate containers as not to cause potential cross contamination. In addition they failed to ensure test strips used for chemical sanitation were not expired. This had the potential to effect all residents residing in the facility. Observation on [DATE] at 10:44 am in the facility kitchen identified a packaged raw turkey and fully cooked turkey both sitting in a sink touching each other with a stream of water running over the raw turkey to thaw. Interview on [DATE] at 10:45, with (cook)-A identified this is a normal routine, after the frozen meat is partially thawed they place it in a container and it is moved to the refrigerator. […]

• No harm, potential for more than minimal, patternF761Aug 3, 2023

  Based on observation, interview and document review the facility failed to ensure expired medication was removed from 2 of 2 medication carts and not administered to 6 of 6 residents (R4, R6, R21, R24, R26 and R27). Findings include: Observation and interview on 8/1/23 at 3:30 p.m., with registered nurse (RN)-A and RN-B during review of the two medication administration carts identified outdated medications had not been removed from the medication administration carts when the documented expiration dates had occurred and had resulted in expired medication being administered to residents. […]

• No harm, potential for more than minimal, patternF883Aug 3, 2023

  Based on interview and document review, the facility failed to ensure 5 of 5 residents (R11, R12, R15, R17, and R27) were appropriately vaccinated against pneumococcal disease upon admission and/or offer updated vaccination per Centers for Disease Control (CDC) vaccination recommendations. This had the ability to affect all 30 residents. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. […]

• No harm, potential for more than minimal, isolatedF600Apr 2, 2025

  Based on observation, interview and document review the facility failed to protect 1 of 1 resident (R8) from abuse. Findings include: Review of 3/29/25, report to the State Agency (SA) identified the DON was notified that an incident had occurred where NA-A had hit R8 in the stomach 3/27/25. The DON assessment of R8 was completed with no visible signs of injury to R8, no pain cues, and no change in behavior was noted. An investigation started. R8's 2/11/25, Significant Change, Minimum Data Set (MDS) assessment identified R8 had a severe cognitive deficit with continuous inattention and disorganized thinking. She had an altered level of consciousness and was dependent on staff for all her cares. R8 was on scheduled pain medication and had no indicators of pain displayed. […]