Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avantara Clark City during CMS and state inspections, most recent first.
Staff failed to follow infection control practices involving Foley catheters, hand hygiene, and EBP. An RN administered meds to multiple residents without sanitizing hands between residents, a CNA allowed Foley tubing to drag on the floor while moving a resident, and another resident’s drainage bag was placed above bladder level during a lift transfer and later left on the floor. A CNA also transferred a resident on EBP without gown and gloves and did not clean the lift afterward.
Smoking safety and supervision failures occurred when a resident assessed as unsafe to smoke independently was observed smoking with flammable items present in the designated area, including a gas can and snow blower, and later sustained cigarette burns. Another resident who required supervision was left unattended while smoking, and flammable acetone was used nearby. The facility also had door security failures involving a cognitively impaired resident with repeated elopement behaviors who was able to exit through unsecured or malfunctioning doors and enter restricted areas.
Failure to report resident cigarette burns: A resident with intact cognition, nicotine dependence, and mild vascular dementia had a smoking evaluation and care plan requiring supervision, a smoking apron, and a cigarette holder because he smoked past the filter and had a history of burns. He was observed smoking with a CNA who lit the cigarette for him and removed it when he would not stop near the filter. The resident later had burns on his thumb and finger, but the administrator was not aware of the injury and the event was not reported to the SD DOH within 24 hours.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
A resident suffered a skin tear on her ankle due to an unprotected bed frame during a transfer. The bed frame had exposed metal bars without protective caps, which were not addressed until after the incident. Staff interviews revealed a lack of communication and action regarding the maintenance issue, and the injury was not initially reported through the facility's TELS system.
Infection Control Lapses With Foley Catheters, Hand Hygiene, and EBP
Penalty
Summary
Staff failed to follow infection control practices related to Foley catheters, hand hygiene, and enhanced barrier precautions. During medication administration in the dining area, an RN was observed giving medications to multiple residents during the noon meal without sanitizing her hands between residents. The facility’s hand hygiene policy required hand hygiene before and after direct resident contact, when entering and leaving resident care areas, before donning and after removing gloves, and before preparing or handling medications. Two residents with Foley catheters were observed with catheter care concerns. One resident was pushed in a wheelchair while his catheter tubing dragged on the floor and he stepped on it multiple times; the CNA stated she was not aware the tubing was not supposed to be on the floor and said it was typical to see it there. Another resident, who had a Foley catheter, a urinary drainage bag, and was on enhanced barrier precautions because of the catheter and a history of urinary retention and MRSA urinary tract infection, was transferred with a total body lift. The drainage bag was hung on the sling above bladder level during the transfer, later attached to the bed below bladder level, then left lying on the floor before a bin was obtained. Enhanced barrier precautions were also not followed during transfer of a resident on EBP. A CNA transferred the resident with a sit-to-stand lift without wearing a gown or gloves and placed the lift in an empty room afterward. A housekeeper stated she witnessed the CNA not clean the lift after use, while the CNA stated he had cleaned it. The DON stated the facility expected urinary drainage bags to remain below bladder level and off the floor, catheter tubing to be off the floor, dirty gloves to be removed before cleaning mechanical lifts, and staff to wash hands after removing gloves and before touching the dirty utility room keypad.
Smoking Safety, Supervision, and Door Security Failures
Penalty
Summary
The facility failed to keep the smoking area free of flammable materials and failed to provide the level of supervision and smoking assistance identified in resident assessments and care plans. Resident 2 had diagnoses of nicotine dependence and mild vascular dementia, had been assessed as not a safe smoker, and his smoking evaluation stated he was careless with smoking materials, unable to safely light a cigarette, and required smoking management and supervision. His care plan directed that smoking materials be kept at the nurses’ station, that he wear a smoking apron, use a cigarette holder, be pushed up to the table, and be supervised while smoking because he smoked cigarettes down to the filter and had a history of burns to his feet from dropping ash. During observation, resident 2 was taken to the designated smoking area and staff lit his cigarette for him, but a snow blower and a gas can were present in that smoking area. Staff confirmed the gas can was about half full and was approximately 8 to 10 feet from the resident while he smoked. Staff also stated there was no signage posted to identify the area as the designated smoking area or to warn that flammable materials were not supposed to be there. Resident 2 later had cigarette burns to his right thumb and right pointer finger, and the physician was notified of those burns. The facility also failed to supervise resident 26 while smoking even though his care plan stated he needed supervision due to deconditioning from hospitalization. Staff interviews showed conflicting understanding about whether he could smoke alone, and the smoke box note stated that both resident 2 and resident 26 were to be supervised. Despite this, resident 26 was observed smoking outside without supervision, and staff left him unattended. In addition, a regional maintenance employee used acetone, identified as extremely flammable, about 10 feet away from resident 26 while he was smoking. The facility further failed to ensure exit and interior doors functioned appropriately in relation to resident 37, who had severe cognitive impairment and a history of wandering and elopement behaviors. Records showed multiple prior incidents of exit-seeking, pushing on alarmed doors, entering other residents’ rooms, and leaving secured areas. On one occasion, resident 37 exited through a storage area door, walked to an employee entrance, and was able to enter after knocking. On another occasion, he entered a housekeeping closet after staff left the door open and was found inside the room. Door audit records and staff interviews showed inconsistent door monitoring and varying reports about whether doors were functioning properly, and the front door could be opened by pushing a green button that was not always monitored after business hours.
Failure to Report Resident Cigarette Burns
Penalty
Summary
The provider failed to report to the South Dakota Department of Health that one resident received cigarette burns to his fingers. The resident had a BIMS score of 13 indicating intact cognition, diagnoses of nicotine dependence and mild vascular dementia, and no physician order to smoke. His smoking evaluation identified that he was careless with smoking materials, unable to safely light a cigarette, not considered a safe smoker, and required smoking management and supervision. His care plan directed that he be supervised, wear a smoking apron, use a cigarette holder to prevent burns because he smoked past the filter, and be pushed up to the table when smoking due to a history of burns to his feet from dropping ash. The resident's physician was notified that he had cigarette burns to his right thumb and right pointer finger, described as brown and tan without signs of infection. During observation, a CNA put his coat and smoking apron on him, handed him the cigarette, and lit it for him; when the cigarette got close to the filter, she encouraged him to put it out, and when he did not, she removed it from his hand and extinguished it. The administrator stated the resident should have used a cigarette holder as indicated on his smoking evaluation, but the facility had been out of cigarette holders for about a week and he should not have been allowed to smoke without one. The administrator also stated she was not aware of the burns and would have reported them to the SD DOH within 24 hours if she had known.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Resident Injured by Unprotected Bed Frame
Penalty
Summary
The provider failed to maintain a bed frame free of hazardous sharp areas, resulting in a skin tear for a resident. The incident occurred when the resident was being transferred into bed, and her right lower outer ankle was cut by the metal on the bed frame. The skin tear was significant, measuring 6.0 cm in length, 3.0 cm in width, and 0.5 cm in depth. Despite the injury, the resident and her family declined to go to the emergency room for evaluation. Observations revealed that the bed frame had exposed metal bars, some of which lacked protective caps, contributing to the hazard. Interviews with staff indicated a lack of communication and action regarding the maintenance of the bed frame. The administrator acknowledged that maintenance staff had not been notified about the issue until after the incident, despite being informed over the weekend. The registered nurse and certified nursing assistant involved did not identify the bed frame as a hazard initially, and the issue was not reported through the facility's communication system, TELS. The director of nursing confirmed that equipment problems should have been reported and investigated following the resident's injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clark
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jenkin's Living Center | 30.5 mi | ★★★★★ | 6 | 0 |
| Avantara Watertown | 30.9 mi | ★★★★★ | 29 | 2 |
| Sun Dial Manor | 31.7 mi | ★★★★★ | 1 | 0 |
| Bethesda Home | 33.1 mi | ★★★★★ | 8 | 0 |
| Avantara Lake Norden | 33.1 mi | ★★★★★ | 2 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.