Seven Sisters Living Center

In the surveyor’s words

From the most serious findings on record at Seven Sisters Living Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 25, 2025

  Based on observation, record review, South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, and policy review, the provider failed to identify and implement interventions to prevent one of one sampled resident (2) from having been burned by a baseboard heater. Findings include: 1. Observation on 6/25/25 at 11:15 a.m. of the lounge area next to the nurses' station revealed: *An open area with large windows that extended from the ceiling to close to the floor. *Beneath the bottom of the windows were two separate metal baseboard heating units. They were cool to the touch. […]

• Actual harm, isolatedF692May 12, 2022

  Based on observations, interviews, record review, and policy review, the provider failed to ensure one of one resident (3) who was at nutritional risk received ongoing monitoring of nutrition and revisions in care as her nutritional status changed. Findings include: 1. Observations on 5/9/22 at 3:56 p.m., on 5/10/22 at 8:04 a.m. and at 1:35 p.m. of resident 3 revealed she appeared thin and weak. Review of resident 3's medical record revealed: *An admitted [DATE]. *Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *She was diagnosed with COVID-19 on 1/21/22. *She had been admitted to hospice on 4/27/22 with an admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *Her weight on: -1/4/22 was 117 pounds. -2/10/22 was 104.5 pounds. -2/15/22 was 108 pounds. -3/9/22 was 106 pounds. […]

• Actual harm, isolatedF742May 12, 2022

  Based on observation, interview, record review, job description review, and policy review, the provider failed to: *Arrange for timely behavioral health follow-up after one of one sampled residents (31) hospitalization for an opioid overdose. *Identify, implement, and evaluate interventions for caregivers to follow for one of one sampled resident (31) who had: -Recently returned to the facility after a fall in her home and now required long term care. -A history of mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Multiple medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. Observation and interviews on [DATE] at 4:02 p.m. and [DATE] at 10:45 a.m. with resident 31 revealed she: *Had been in her room lying in her bed. […]

• No harm, potential for more than minimal, widespreadF755Jul 25, 2024

  Based on South Dakota Department of Health (SD DOH) complaint report review, interview, record review, and policy review, the provider failed to ensure prompt identification of loss or potential diversion of controlled (high risk for addiction and dependence) medications and prompt identification of medication errors. Failure to accurately monitor controlled medications and medication errors may have placed the residents at increased risk of adverse effects of not receiving medications as ordered, such as increased pain. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the identification of the incident. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF880Jul 25, 2024

  Based on observation, interview, record review, and policy review, the provider failed to ensure: *Proper hand hygiene, glove use, containment of soiled linen, and disinfection of a mechanical lift, by two of two staff (M and N) during one of one sampled resident's (46) mechanical lift transfer and personal hygiene care. *Proper hand hygiene, glove use, containment of soiled linen, and suprapubic catheter (connected through the abdomen to the bladder) care by one of one medication aide (Q) during one of two sampled resident's (1) catheter care observations. […]