Avera Brady Health and Rehab: Call Light Failures - SD
The April 2027 complaint inspection at Avera Brady Health and Rehab in Mitchell, South Dakota, surfaced two problems that, taken together, describe a facility where a resident's ability to summon help was less reliable than it appeared, and where staff attention to at least one resident had slipped far enough that the corrective measure was simply to ask what had happened.
Inspectors rated the harm level as minimal, or potential for actual harm, affecting few residents. That rating reflects the regulatory floor, not the ceiling of what the records describe.
The entry about Resident 41 is brief and, because of that, striking. Her name is redacted, as required. What remains is a column labeled "Action" and a single nursing directive: assess with the resident why she is sitting for so long. The inspection record does not say how long she had been sitting. It does not say whether she had tried to call for help. It does not say whether she had a call light within reach, or whether that call light worked.
That last question matters more than it might seem.
The facility's call system used a device called the ES Call Station, a wireless, battery-operated unit manufactured under the Arial brand. Inspectors reviewed the manufacturer's installation guide during the inspection. The guide describes a system designed to be simple: residents press a large blue button, pull a red cord, or use an optional push-button cord to trigger an alarm. When an alarm fires, a red LED lights up and stays lit until a staff member cancels it. The call station sends a supervision signal to the facility's server roughly every five minutes.
The manufacturer's guide included a warning in plain language. Inspectors copied it into the inspection record directly: if a facility uses the optional push-button cords, staff must inspect all connectors following every alarm. If the electrical connections are not sound after an alarm, the next time a resident tries to use that cord, it may not send an alarm at all. The guide used the words "injury or death."
That warning is not a hypothetical buried in fine print. It is a specific, operational instruction: after every single alarm, check the cord. If the check does not happen, the next resident who reaches for that cord and pulls it may get nothing. No alarm. No LED. No response. No way of knowing the signal never left the room.
Inspectors reviewed the facility's own call light policy, dated August 2024. The policy required a functioning call light system. It set a response-time goal: staff should answer call lights within ten minutes at least 87 percent of the time. If a call light was found to be defective, staff were required to report it immediately to maintenance.
The policy said nothing about the manufacturer's post-alarm inspection requirement for push-button cords.
That gap is the problem inspectors identified. The facility had a policy. The manufacturer had a separate, more specific instruction. The two did not match. Whether staff were performing post-alarm connector checks, whether anyone had been trained to perform them, whether maintenance logs showed any record of defective cords being reported — none of that appears in the portion of the inspection record available here. What appears is the warning itself, reproduced in full, and the facility's policy that did not account for it.
The inspection record does not say how many residents used push-button cords. It does not say whether any cord had ever failed after an alarm. It does not say whether Resident 41 used a push-button cord or whether her sitting had anything to do with the call system at all. The record does not connect those two findings explicitly.
But they appeared in the same inspection, at the same facility, in the same week.
Resident 41's situation is documented in what appears to be a care plan or corrective action log. The column structure — with action items assigned to nursing — suggests the facility had already identified that something was wrong with her care before or during the inspection, and had written a response. That response was a question. Go ask her why she's been sitting so long.
It is worth sitting with that for a moment. Not a change in her positioning schedule. Not an investigation into whether she had been checked on, or whether her call light had been answered, or whether she had been able to reach her call device. The documented corrective action was to have a nurse ask the resident to explain her own neglect.
The inspection covered a complaint, meaning someone contacted regulators before inspectors arrived. The nature of that complaint is not detailed in the available records. Whether it came from a family member, a resident, or a staff member is not stated. What is stated is that inspectors found enough to document two distinct deficiencies: one involving a resident's positioning and care, one involving a call system that carried a manufacturer's warning about silent failure.
Avera Brady Health and Rehab is a long-term care and rehabilitation facility. The inspection was conducted on April 27, 2026. The CMS form number on the inspection document is 2567, the standard federal form used to record deficiencies found during nursing home inspections.
The manufacturer's warning about the push-button cord is worth reading one more time, because it is precise in a way that regulatory language often is not: inspect all connectors following every alarm, and if good electrical connections are not being made, subsequent use of the push-button cord may not issue an alarm, which could lead to the injury or death of a resident. The company that built the device wrote those words. They wrote them because the failure mode is real, because it has presumably happened, because a device that appears functional can stop working after a single use without giving any visible indication that it has done so.
A resident who pulls that cord gets silence. The red LED stays dark. No one comes.
Whether Resident 41 pulled a cord and got silence, or whether she simply sat because no one came to help her move, the inspection record does not say. What it says is that she sat long enough that someone noticed, long enough that it made it into a corrective action log, and that the action taken was to ask her why.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avera Brady Health and Rehab from 2026-04-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
AVERA BRADY HEALTH AND REHAB in MITCHELL, SD was cited for violations during a health inspection on April 27, 2026.
Inspectors rated the harm level as minimal, or potential for actual harm, affecting few residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.