Sunset Manor Avera Health
Inspection Findings
F-Tag F0678
F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
residents' care needs and interventions) that the staff members were to carry with them while they worked.*They stated they had not performed any auditing or monitoring to ensure the residents' code statuses were identified or that the staff were aware of the expectations regarding their processes for providing life sustaining measures according to a resident's code status after resident 52's incident. 4.
Interview on [DATE REDACTED] at 9:45 a.m. with LPN L revealed:*She had started working at the facility in [DATE REDACTED].*She had received general education regarding advance directives and code status.*She explained
she would not start CPR on a resident with a DNR code status if the resident was unresponsive with no pulse or respirations.*Resident code statuses were identified in the EMR and the hall sheets. 5. Interview
on [DATE REDACTED] at 9:57 a.m. with LPN D revealed:*She started working at the facility in [DATE REDACTED].*Resident code statuses were identified in the EMR and the hall sheets.*In an emergency, she would check a resident's code status before beginning CPR.*She received mandatory education about advance directives and code statuses. 6. Interview on [DATE REDACTED] at 10:09 a.m. with certified nursing assistant (CNA) J revealed:*She had worked at the facility for about a week.*She was CPR certified.*She watched orientation training videos, but
they did not provide education specifically regarding a resident's code status.*Resident's code statuses were identified in the EMR and the hall sheets. 7. DON B was unable to provide signed education documentation of the nursing staff to verify who attended the nurses meeting on [DATE REDACTED] after resident 52's [DATE REDACTED] incident. 8. Review of the provider's new hire orientation and annual education for staff revealed
they provided education on advance directives and resident code statuses. 9. Review of the provider's reviewed 10/2025 LTC Code Status/Resuscitation policy revealed:* To provide staff with accurate information in the event of cardiac and/ or respiratory arrest.* e. A ‘Medical Emergency' [a health condition or situation that needs immediate medical attention] is initiated on any resident needing emergency resuscitation due to a cardiac and/ or respiratory arrest unless there is a ‘Do Not Resuscitate' order documented in the resident's electronic medical record. 10. Review of the provider's [DATE REDACTED] Advance Directive policy revealed:* It is the policy of this facility will provide basic life support, including CPR Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order and resident choice indicated in the resident's advance directives. Nurses are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless: A valid Do Not Resuscitate order is in place.
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Sunset Manor Avera Health in IRENE, SD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in IRENE, SD, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Sunset Manor Avera Health or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.