Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Huron during CMS and state inspections, most recent first.
Failure to Protect Residents from Sexual Abuse During Incontinence Checks: A resident with intact cognition reported that a CNA pulled back her blankets and checked her brief in a way that startled her, and another cognitively intact resident reported that a female staff member put her hand down her pants and inside her underwear during a night shift to check if she was dry. The DON and SSD treated the first allegation as a lack of education rather than abuse, did not report it as required, and did not document or expand the investigation to other residents or staff. A COTA also reported that similar concerns had been raised by other residents.
Two residents experienced preventable safety incidents due to inadequate supervision and failure to follow care plans. A resident with severe cognitive impairment and documented high elopement risk exited through the front door unnoticed after following a staff member, while the receptionist’s view was obstructed by multiple visitors entering, allowing the resident to reach the parking lot before being brought back inside. In a separate event, a resident at high fall risk, whose care plan required one-person assist with a gait belt for transfers, was transferred by a CNA from a bath chair to a wheelchair without a gait belt; the resident could not continue standing and was eased to the floor, resulting in a skin tear to the eyebrow and a large bruise on the upper arm, despite stable vitals and baseline ROM and neuro status.
Delayed response to call lights affected two cognitively intact residents. One resident with urinary incontinence and reduced mobility reported that slow call light response sometimes led to urinary incontinence, and her call light logs showed repeated waits over 15 minutes. Another resident with fractured ribs reported waiting up to an hour for help to the bathroom or for PRN pain medication, felt upset when staff seemed to forget her, and had multiple call light delays over 15 minutes. Staff interviews showed inconsistent pager use and expectations that call lights be answered within 5 to 15 minutes.
Failure to thoroughly investigate sexual abuse allegations: Two cognitively intact residents reported that staff touched their private areas while checking for incontinence, causing embarrassment and distress. One resident said a CNA pulled back her blanket and checked her brief, while another said a female staff member put her hand down her pants and inside her underwear. The DON and SSD did not fully investigate the complaints, did not interview other residents or staff about similar incidents, and the alleged sexual abuse was not reported to the state or law enforcement as required by policy.
Unsafe food temperatures and missing hair restraints were observed during meal service. In one kitchenette, egg salad sandwiches were initially 45 F and later 50 F, and milk on a resident tray was 60 F; multiple staff, including the DON, RN supervisor, MDS coordinator, CNAs, and others, washed hands near uncovered food without hair nets or hair restraints. In another kitchenette, uncovered food was in the steam table while the SSD, staffing coordinator, medical records director, and RN/MDS coordinator washed hands without proper hair restraints.
Failure to report sexual abuse allegations: Two cognitively intact residents reported that staff touched them while checking for incontinence, including one resident who said a CNA pulled back her blanket and touched inside her brief and another who said a female staff member put her hand down inside her pants and underwear. The DON and SSD treated the events as non-abusive or as education issues, and the allegations were not reported to SD DOH or law enforcement as required by policy.
Failure to Notify Physician of Significant Weight Loss: Two residents had significant unplanned weight loss, including one with a 17.8% loss and another with a 5% loss in one month. Staff observed poor intake, meal refusals, and one resident’s hunger strike, but there was no documentation that the RN/LPNs, DON, or RD notified the physician of the weight loss or that required reweights were completed. One resident also had poor dentition and difficulty chewing, while the other was on a modified texture diet with a nutrition intervention plan and continued to eat very little.
MDS assessments were inaccurately coded for medications and PASRR status for multiple residents. One resident’s MDS failed to identify an antidepressant despite an active Escitalopram order, and two residents had PASRR-related coding errors on comprehensive MDS assessments even though records showed serious mental illness and/or a PASRR Level II status. Interviews confirmed the RN/MDS coordinator acknowledged the miscoding, while SSD completed PASRR screenings and the RN/MDS coordinator entered the MDS data.
A resident was admitted with a PASRR Level 1 that did not indicate mental illness, then later had unspecified psychosis documented in the EMR. The SSD stated she did not complete a PASRR Level II and was not aware whether nursing staff notified her of the updated diagnosis. Facility policy required a Level II PASRR evaluation and determination for individuals with suspected or confirmed mental illness.
Incomplete baseline care plans within 48 hours of admission: Two residents had baseline care plans that were not fully completed after admission. One resident's plan did not include transfer information, and another resident's plan did not include transfer information or diet information. The RN supervisor verified the omissions, while the DON stated transfer information was expected but believed diet could be listed as 'diet as ordered' instead of being fully included in the baseline care plan.
Care plans were not updated to reflect current resident needs for three residents. One resident with an abdominal drain did not have EBP, drain-related information, or room signage reflected in the care plan when staff were providing direct care. Another resident’s care plan did not include PASRR recommendations related to serious mental illness. A third resident receiving hospice services had a hospice plan in the EMR, but it was not incorporated into the facility care plan or pocket care plans used by staff.
Staff failed to follow infection control practices for residents on EBP and during catheter and skin care. Two residents with indwelling devices did not have PPE supplies or EBP signage available as expected, and staff interviews showed the resident care information had not been updated consistently. During care for a resident with a Foley catheter and open skin areas, a CNA reused contaminated gloves while cleaning the catheter tubing and nearby skin, and an LPN did not perform hand hygiene before putting on clean gloves to apply powder.
Two incidents of neglect occurred when CNAs failed to follow care plans. One resident was left in the same clothes and incontinent overnight, while another fell during an improper transfer. Both incidents involved miscommunication and failure to adhere to care plans, resulting in neglect.
The facility failed to maintain sanitary conditions in the kitchen, with improper temperature monitoring and food storage practices. Observations revealed temperature discrepancies in the walk-in freezer and fridge, with no corrective actions documented. Interviews with dietary staff highlighted a lack of knowledge and documentation regarding temperature checks and food disposal. The facility's policies on freezer defrosting, food storage, and temperature recording were not followed, leading to unsanitary conditions.
The facility failed to maintain an ice machine in a sanitary manner, with pink slime and rust observed. Two residents with MRSA were not placed on contact precautions, contrary to policy. An LPN did not follow proper infection control practices during medication administration for a resident on COVID-19 precautions. Staff interviews revealed inadequate cleaning procedures and lack of recent education on infection control.
The facility failed to provide baseline care plan summaries to fourteen residents within 48 hours of admission. Staff interviews revealed that the social services designee did not review or provide summaries due to insufficient training, and the RN did not document the reviews in the EMR. The facility's policy mandates completion of baseline care plans within 48 hours, which was not followed.
A facility failed to provide bed-hold notices to a resident and their representative during two hospital transfers. The resident's records showed three hospital transfers, but only the first included a bed-hold notification. An interview confirmed the lack of documentation for the latter transfers. The facility's policy requires informing residents or their representatives of the bed-hold option at admission and upon each transfer.
A resident's care plan was not updated to include contact precautions after a MRSA diagnosis, and lacked interventions for her behavior of barricading herself in her husband's room. The care plan also did not address the use of family as an intervention, despite their involvement. Additionally, Prevalon boots were used but not listed as an intervention for her wounds.
A resident with a history of surgery and multiple diagnoses reported pain, but the facility failed to provide adequate pain management. Despite having an order for Tramadol, the medication was unavailable due to a missing prescription, and the resident's care plan interventions were not effectively implemented. Interviews revealed a lack of follow-up with the physician and inconsistencies in entering standing orders into the EMR.
A resident requiring dialysis treatment was not properly monitored upon returning from dialysis sessions. The facility failed to consistently document the resident's vital signs post-dialysis, with some entries using outdated data. Interviews revealed that the process for obtaining and documenting these vital signs was not consistently followed, leading to incomplete records.
The facility failed to maintain cleanliness in the kitchen, with range hood vents covered in grease, an ice machine with hard water scale, and stained ceiling tiles. The range hood was not on the weekly cleaning schedule, and maintenance had not cleaned the vents in June. The ice machine was due for replacement, and the ceiling stains were attributed to condensation. The cleaning tasks were marked as completed in previous months, but the provider's policy required compliance with cleaning schedules.
Failure to Protect Residents from Sexual Abuse During Incontinence Checks
Penalty
Summary
The facility failed to protect residents from sexual abuse when a CNA and an unidentified staff member were reported to have touched residents in their private areas during incontinence checks without consent. Resident 57, who had intact cognition with a BIMS score of 15 and diagnoses including generalized anxiety disorder, major depressive disorder, agoraphobia, and other manic episodes, reported that during night rounds a CNA pulled back her blankets and checked her incontinence brief in a way that startled her. She later stated the CNA touched the inside of her brief, though at another point she was unsure whether the contact was inside or outside the brief. Resident 57 was independent with toileting and reported the concern to RN H, who relayed it to DON B. The facility treated the allegation as a lack of education rather than a potential abuse situation. DON B stated CNA D did not mean the contact in a sexually inappropriate way and therefore the incident was not reported to the SD DOH. The internal investigation documentation stated resident 57 did not believe the CNA meant anything inappropriate and that she felt safe, but the report also documented that the CNA said he pulled back the blankets and checked the resident’s brief. SSD F’s notes reflected that resident 57 was startled when staff entered during overnight rounds and pulled down her blanket to check her brief. Interviews also showed that SSD F did not document the follow-up in the EMR, did not interview other residents or staff for similar incidents, and no audits were completed after the incident. A separate complaint involved resident 78, who had intact cognition with a BIMS score of 15 and diagnoses of anxiety disorder and depression. Resident 78 reported that during the night shift a female staff member asked if she needed the bathroom and then put her hand down resident 78’s pants and inside her underwear to check whether she was dry, despite resident 78 saying no. Resident 78 reported the incident to COTA E, who took her to SSD F. Resident 78 stated she made a formal complaint and later did not see anything about the incident in her discharge paperwork. COTA E stated this was not the first time residents had reported staff ripping off blankets and feeling around to check for incontinence, and she recalled other residents still in the facility who had reported similar concerns. SSD F and DON B denied awareness of other such allegations and did not document or investigate additional residents or staff regarding the reports.
Failure to Prevent Elopement and Injury Due to Inadequate Supervision and Noncompliance With Transfer Protocols
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents. In the first incident, a resident with severely impaired cognition, as evidenced by Brief Interview for Mental Status (BIMS) scores of three and zero on prior assessments, had been identified as a high elopement risk with elopement risk assessment scores of five on two separate dates. Her care plan prior to the incident included non-pharmaceutical interventions for wandering, such as cueing, reorienting, supervising, use of an animatronic dog, conversation, walking with her, inviting her to activities, encouraging rest, and providing less stimulation when she was anxious, delusional, or wandering. Despite these identified risks and interventions, the resident was able to exit the building through the front door without staff knowledge. On the date of the elopement, the resident was ambulating with a walker throughout the facility and followed a staff member who was leaving the property out the front door. She exited the building at 2:48 p.m. and was seen outside in the parking lot by the front door at 2:50 p.m., at which time she was escorted back into the facility. The DON later stated that during this elopement, a staff member let in five family members through the front door, which crowded the receptionist’s direct line of sight and prevented the receptionist from seeing the resident use her walker to leave the facility. The DON also stated that residents were mobile and deemed elopement risks, and that if they got outside, it was considered an elopement based on facility policy. The facility’s elopement policy required the facility to take steps to keep residents safe and assess residents to identify those at risk for elopement. The second incident involved a resident with a care plan indicating she was to be transferred with one-person assistance using a walker and a gait belt, and who had been assessed as being at high risk for falls. On the date of the fall, a CNA assisted this resident from a bath chair to her wheelchair without using a gait belt, contrary to the resident’s care plan and the facility’s Transfer and Gait Belt Use policy. During the transfer, the resident was unable to continue standing, and the CNA eased her to the floor, where she was found lying on her right side at the foot of her bed. Assessment by an LPN revealed a one-centimeter skin tear to the right eyebrow, which was closed with a steri-strip, and a light blue bruise measuring ten centimeters by three centimeters on the right upper arm. The resident’s range of motion, neurological assessments, and vital signs were within normal limits, and she reported pain at a level of three on a zero-to-ten scale. The CNA later confirmed he knew a gait belt was required for this resident but did not use one and was unsure why.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure staff responded promptly to call lights for two residents who reported delays in getting assistance. One cognitively intact resident with diagnoses of reduced mobility, urinary incontinence, and urinary tract infection stated that call lights were sometimes not answered quickly enough, which caused urinary incontinence. Her care plan required assistance from one staff member to use the bathroom, and her call light response time report showed multiple instances lasting 15 minutes or longer, including several over 20 minutes. Another cognitively intact resident with unspecified depression and multiple fractured ribs on the right side reported waiting up to an hour for her call light to be answered when she needed help to the bathroom or pain medication, and she said she felt upset and as if staff had forgotten about her. Her MAR showed PRN oxycodone was administered for pain, and her call light report documented nine response times greater than 15 minutes, including several lasting 20 to 39 minutes. Staff interviews indicated the facility expected call lights to be answered within 5 to 15 minutes, but one CNA reported not having a pager, an LPN stated pagers were locked in the medication room and exchanged for personal items, and a contracted CNA said she did not know the facility had pagers.
Failure to Thoroughly Investigate Sexual Abuse Allegations
Penalty
Summary
The provider failed to ensure that allegations of sexual abuse involving two cognitively intact residents were thoroughly investigated after each resident reported that staff had touched their private areas without consent while checking for incontinence. One resident, who had a BIMS score of 15 and diagnoses including generalized anxiety disorder, major depressive disorder, agoraphobia, and other manic episodes, reported that a night CNA startled her by pulling back her blanket and checking her brief. Another resident, who also had a BIMS score of 15 and diagnoses of anxiety disorder and depression, reported that a female staff member put her hand down her pants and inside her underwear to check whether she was dry, which made her feel embarrassed and later caused nightmares and an eerie, gross feeling. The facility’s response to the first resident’s allegation was limited to internal discussion, a social services visit, and staff education. The DON stated she did not report the incident to the state because she believed the CNA did not mean it in a sexually inappropriate way and because she believed the resident said she was not touched inappropriately. The internal investigation documentation reflected that the resident was told the CNA may not have known her routine and that she did not believe the CNA meant anything inappropriate. The investigation also stated that the physician, police, ombudsman, and state agency were not notified. The DON acknowledged that no audits were completed after the incident and that no other residents were interviewed to determine whether similar incidents had occurred. The second resident reported the incident to therapy staff and then to social services, stating that no one from the facility followed up with her after she made the formal complaint. The social services designee did not recall the resident bringing the complaint to her office and stated she did not document the follow-up in the EMR, did not speak with other staff or residents, and did not offer additional counseling. The DON stated she only received the complaint involving the first resident and did not interview other residents about similar concerns. A therapy staff member reported that multiple residents had complained over the prior months that staff ripped off blankets and felt around to check for incontinence, including residents who were both continent and incontinent. The facility policy required immediate investigation of abuse allegations, interviewing all people who might know information, protecting residents, and reporting sexual abuse allegations to law enforcement the same day, but those steps were not carried out as described in the report.
Unsafe food temperatures and missing hair restraints during meal service
Penalty
Summary
Food was not maintained and served at safe temperatures during observed meal services, and staff did not follow hair restraint requirements while working around exposed food. During the supper service in the Independence kitchenette, cook GG brought in pre-made egg salad sandwiches on ice and took their temperature at 45 degrees F. While uncovered food was in the steam table and on the cart, multiple staff members washed their hands behind the kitchenette sink without wearing hair nets or hair restraints, including CNAs, an RN supervisor, the DON, the MDS coordinator, and other staff. Cook GG later began plating the egg salad sandwiches, retook the temperature at 50 degrees F, and stated they were above the required 41 degrees F. She also checked milk on a resident room tray and found it at 60 degrees F. The egg salad sandwiches were not served until new sandwiches were brought in at under 41 degrees F. During the lunch service in the [NAME] kitchenette, food was uncovered in the steam table while staff washed their hands in the kitchenette without hair nets or hair restraints. Observed staff included the SSD, staffing coordinator, medical records director, and RN/MDS coordinator, with one staff member’s ponytail not containing all of her hair. The provider’s policies stated cold food and dairy products were to be served at 41 degrees or colder and that staff shall wear hair restraints in food production, dishwashing, or serving areas to prevent hair from contacting exposed food.
Failure to Report Sexual Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse reporting policy after two residents reported that staff members touched them while checking whether they were incontinent. One resident, who had intact cognition with a BIMS score of 15 and diagnoses including generalized anxiety disorder, agoraphobia, major depressive disorder, and other manic episodes, reported that a night CNA startled her during rounds by pulling back her blanket and checking her brief. She later stated that the CNA touched the inside of her incontinence brief, while other interviews reflected uncertainty about whether the brief or private area had been touched. The resident was independent with toileting and reported feeling safe at the facility during some follow-up conversations, but she also became tearful when describing the incident. A second resident, who also had intact cognition with a BIMS score of 15 and diagnoses of anxiety disorder and depression, reported that a female staff member put her hand down inside her pants and underwear during a night shift to check whether she was dry. She stated that she told a COTA about the incident the next day and was brought to social services to report it. She described feeling uncomfortable, having nightmares about the event, and later filed a complaint with the state because she did not see the incident addressed in her discharge paperwork and did not receive follow-up from the facility. She was independent with toileting at the time of the incident. Facility interviews and records showed that the DON and SSD treated the incidents as non-abusive or as education issues and did not report them to the SD DOH or law enforcement. The internal investigation for the first resident stated that the staff member did not touch her and that the event did not rise to the level of abuse or neglect, despite the resident’s report that her brief was checked by touching and the facility policy defining sexual abuse as actual or implied sexual contact between caregiver and resident. The abuse and neglect policy required allegations of sexual abuse to be reported to local police the same day and to the state agency within two hours, and it required immediate investigation and protection measures. The report states that the provider failed to implement those reporting requirements for both residents’ allegations.
Failure to Notify Physician of Significant Resident Weight Loss
Penalty
Summary
The facility failed to notify the physician of two residents who had unplanned significant weight loss. One resident had a 17.8% weight loss, dropping from 173.4 pounds on admission to 142.6 pounds over 27 days, with weekly weights showing repeated losses and no documentation that she was reweighed after the documented declines or that the physician was notified. She was on a regular diet with mechanical soft textures and a Nutrition Intervention Plan, and her care plan directed staff to monitor for weight loss, dehydration, and difficulty chewing or swallowing. Staff interviews showed that multiple nurses and supervisors were aware of her poor intake, refusal to eat, and statements that she was on a hunger strike, but they did not notify the physician of the weight loss. The resident was observed eating very little during meals, moving food around on her plate, taking only small bites or none at all, and declining offered alternatives. Her record showed numerous meals with 0-25% intake, meals documented as refused, and many meals with no intake documentation. The bath aide and nursing staff described a process in which weights were recorded on bath sheets and reviewed later, but the record contained no documentation of reweighs after the significant losses or physician notification. The physician later stated he noticed a downward trend in weight during visits but had not been notified by nursing staff and expected to be informed when a resident had a 10% weight loss. A second resident lost 5% of body weight in one month, from 133.7 pounds to 125.4 pounds. She had poor dentition with broken front teeth that made chewing certain foods difficult, but she did not want a dental visit or a specialized diet. Her record showed a history of weight loss and nutrient deficiencies, and staff documented that she ate partial meals over the prior 30 days. There was no progress note showing that the physician was notified of her weight loss. Interviews with nursing and dietary staff confirmed that a resident with a 3- to 5-pound change was to be reweighed and that the physician was to be notified if the loss remained significant, but no documentation showed that this occurred for this resident.
MDS assessments were inaccurately coded for medications and PASRR status
Penalty
Summary
The facility failed to ensure that MDS assessments were accurately coded for medications and PASRR status for three sampled residents. For one resident, the 1/28/26 significant change MDS section N identified antipsychotic, antianxiety, opioid, and anticonvulsant medications, but did not identify an antidepressant medication even though the EMR showed an order for Escitalopram 20 mg daily for depression. During interview, the RN/MDS coordinator reviewed the assessment and agreed it was not marked correctly because the resident was taking an antidepressant medication, and stated the MDS section was completed by another RN using the MAR and TAR. For another resident, the EMR showed an approved PASRR Level II on 4/22/25, along with diagnoses including generalized anxiety disorder, other manic episodes, agoraphobia, and major depressive disorder, and physician orders for psychiatric services and psychotropic medications including Lexapro, Depakote, and Seroquel. However, the 10/27/25 comprehensive MDS indicated the resident did not have a PASRR Level II, and the care plan did not reflect the PASRR Level II until 2/22/26. The record also showed that the resident had a PASRR Level II status that should have been reflected on the MDS. For a third resident, the EMR showed bipolar disorder, anxiety disorder, and adjustment disorder with depressed mood, and Level I PASRR screenings on 12/27/23 and 10/16/24 stated the resident had evidence of serious mental illness but did not require further PASRR evaluation because treatment needs had not significantly changed since the previous PASRR Level II evaluation. Despite this, item A1500 on the 5/12/23, 9/26/24, and 9/22/25 comprehensive MDS assessments was coded No, although one earlier assessment had been coded Yes. The RN/MDS coordinator acknowledged the miscoding, and the DON and SSD interviews confirmed that SSD completed PASRR screenings while the RN/MDS coordinator coded the MDS information.
Failure to Complete PASRR Level II for Resident With New Psychosis Diagnosis
Penalty
Summary
The provider failed to complete a Level II Preadmission Screening and Resident Review (PASRR) for one sampled resident who developed a new diagnosis of unspecified psychosis after admission. The resident was admitted to the facility and later had unspecified psychosis documented in the electronic medical record. The resident’s PASRR Level 1 screening form dated 1/19/26 did not indicate a confirmed or suspected mental illness diagnosis. During interview, the social services designee stated that she did not complete a PASRR Level 2 for the resident and that nursing staff were supposed to notify her if there were updates to residents’ diagnoses; she was not aware whether staff informed her of the psychosis diagnosis. The facility policy stated that individuals who have or are suspected to have mental illness, intellectual disability, or a related condition may not be admitted to a Medicaid-certified nursing facility unless approved based on a Level II PASRR evaluation and determination.
Incomplete baseline care plans within 48 hours of admission
Penalty
Summary
The provider failed to ensure that baseline care plans were complete within 48 hours of admission for two newly admitted residents. Resident 42 was admitted to the facility and her baseline care plan, completed on 3/8/26, documented that she required the assistance of one staff member and a gait belt for ambulation and used a wheelchair for long distances, but it did not include how she transferred within 48 hours of admission. Resident 56 was admitted to the facility and her baseline care plan, completed on 3/4/25, documented that she required the assistance of one staff member, but it did not include how she transferred or what her diet was within 48 hours of admission. During interview, the RN nurse supervisor stated that she and the charge nurse completed baseline care plans when residents were admitted and verified that Resident 42's plan should have included transfer information within 48 hours. She also verified that Resident 56's plan should have included transfer information and diet information within 48 hours. The DON stated that baseline care plans were expected to include how the resident transferred within 48 hours of admission, but she did not think the diet needed to be included and believed it was acceptable to state 'diet as ordered.' The facility's Care Plans policy stated that baseline care plans are started on the first day of admission and completed no later than 48 hours after admission, and that they must include minimum healthcare information such as initial goals, physician orders, dietary orders, and therapy services.
Care Plans Not Updated to Reflect Current Resident Needs
Penalty
Summary
The facility failed to ensure resident care plans were reviewed and revised to reflect current care needs for three sampled residents. For one resident with a right abdominal drainage bag and a diagnosis of peritoneal abscess, staff observed that enhanced barrier precautions (EBP) were not in place in the room during initial observation, and the resident stated staff had not used gloves or gowns when emptying the drainage bag. The resident’s record showed an abdominal drain order, an admission assessment identifying the drain, and care plan entries for infection risk and skin impairment, but the care plan did not include EBP or the abdominal drain. Staff interviews confirmed that EBP was not added to the care plan until after admission and that the Kardex and room signage were also delayed. For another resident with bipolar disorder, anxiety disorder, and adjustment disorder with depressed mood, the record showed Level I PASRR screenings identifying serious mental illness and noting that treatment needs had not significantly changed since prior PASRR evaluation. However, there was no documentation that the resident’s revised care plan included the PASRR recommendations. The DON stated she was unaware the PASRR information was missing from the care plan, and the SSD stated she should have included the PASRR information and was still learning. The administrator stated she expected the SSD and RN/MDS coordinator to work together to ensure care plans were updated and accurate. For a third resident receiving hospice services, the EMR included a hospice care plan and hospice notes beginning with hospice admission, but the hospice care plan was not incorporated into the facility care plan used by staff. Staff interviews showed that CNA and RN staff relied on pocket care plans to guide care, and those pocket care plans did not include the hospice goals or interventions. The RN supervisor stated the facility care plan should have been updated to include the hospice care plan when it was initiated. The facility policy stated that individualized, resident-centered care planning would be initiated upon admission and maintained by the interdisciplinary team throughout the resident’s stay.
Infection Control Lapses During EBP, Catheter Care, and Wound Treatment
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed for residents on enhanced barrier precautions (EBP) and during catheter and wound-related care. For resident 82, an LPN was observed placing yellow EBP PPE organizers on the doorway, but the resident’s record showed she had an indwelling Foley catheter and the MDS indicated she was not on isolation or additional precautions. For resident 84, who had a right abdominal drainage bag and a diagnosis of peritoneal abscess, observations showed no PPE supplies in the room and no EBP signage posted on two separate occasions before PPE and signage were later placed on the door. Staff interviews indicated the resident’s Kardex had not reflected EBP until after the deficiency was identified, even though supervisors stated they expected EBP for residents with drains and other indwelling devices. During observation of resident 20’s catheter care, a CNA performed hand hygiene, donned gown and gloves, and then cleaned the resident’s abdominal folds and perineal area. Using the same gloved hands, she cleaned the catheter tubing and then touched the tubing again after cleaning the area near the insertion site. She then used the same gloves to clean under the resident’s right breast, which had red open areas, and acknowledged she should have changed gloves before doing so. The CNA later stated she was to wash her hands and apply new gloves before performing catheter care. In a separate observation of resident 20, an LPN applied antifungal powder to open and reddened skin areas after removing dirty gloves but did not perform hand hygiene before putting on a new pair of gloves. The LPN later stated she should have washed her hands after removing the unclean gloves and before putting on clean gloves. The resident’s record showed she had orders for Miconazole powder and a Foley catheter, had received IV Ertapenem for a UTI, and her care plan indicated she required EBP due to the Foley catheter and catheter care every shift and as needed. The facility’s hand hygiene policy stated staff were to perform hand hygiene before putting gloves on, after taking them off, and when moving from a dirty body site to a clean body site.
Neglect Due to Failure to Follow Care Plans
Penalty
Summary
The provider failed to protect residents from neglect in two separate incidents. In the first incident, a CNA did not provide nighttime care for a resident who was found the next morning in the same clothes from the previous day and incontinent of bowel. The resident had been recently readmitted from the hospital with a history of red and sore buttocks. Despite the resident's care plan being updated upon her return, the CNA and the charge nurse on duty did not ensure the care plan was followed, resulting in neglect. In the second incident, a CNA did not follow the care plan for a resident with moderate cognitive impairment during a transfer. The resident was supposed to be transferred using a stand-up lift during the evening shift, but the CNA attempted a stand and pivot transfer, leading to the resident's fall. The CNA misread the care plan, which clearly indicated the need for a stand-up lift during the evening and night shifts. Both incidents highlight a failure to adhere to established care plans, resulting in neglect. The residents involved had specific care needs that were not met, leading to situations that could have been avoided if the care plans were properly followed. The facility's policies on neglect emphasize the importance of providing necessary and adequate care to avoid harm, which was not achieved in these cases.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The provider failed to maintain clean and sanitary conditions in the kitchen where residents' food was stored and prepared. Observations revealed that the walk-in freezer had temperatures recorded outside the adequate range, with no documented actions taken to address these discrepancies. There was ice build-up around the door, the metal lining was separated, and frost was present on the cooling unit. The three-door fridge unit also had temperature variances without documented corrective actions. Additionally, there were issues with food storage, such as undated chicken nuggets, freezer-burned chicken, and improperly stored meat. Interviews with the dietary manager and aides highlighted a lack of knowledge and documentation regarding temperature checks and food disposal. The dietary manager admitted to not documenting actions taken when thermometers did not match and was unaware of the proper disposal process for food based on package dates. The administrator was aware of the ice build-up but not of the failure to discard partially thawed food. The facility's policies on freezer defrosting, food storage, and temperature recording were not adhered to, contributing to the unsanitary conditions. The provider's policies outlined specific guidelines for freezer defrosting, food storage, and temperature monitoring, which were not followed. Freezers were supposed to be frost-free, and food should not show signs of defrosting or refreezing. The facility's failure to adhere to these policies resulted in unsanitary conditions in the kitchen, with improperly stored and potentially unsafe food items. The lack of documentation and adherence to procedures by the dietary staff further exacerbated the issue.
Infection Control Deficiencies in Ice Machine Maintenance and Resident Precautions
Penalty
Summary
The provider failed to maintain an ice machine in a clean and sanitary manner, as observed in the therapy room. The ice machine had pink slime on the water/ice spout, rusted metal bars over the water tray, and a white, flaky residue on the underside of the machine. Interviews with staff revealed that housekeepers only cleaned the outside of the machine, while maintenance staff were responsible for internal cleaning. However, the maintenance director admitted to using inappropriate cleaning chemicals and not following the manufacturer's instructions for cleaning and sanitizing the machine. The provider also failed to place two residents on contact precautions despite their diagnoses with multi-drug resistant organism (MDRO) infections. One resident had Methicillin-resistant Staphylococcus aureus (MRSA) in her left ankle and was receiving intravenous antibiotics, yet was only on enhanced barrier precautions. Another resident, diagnosed with MRSA in her right ankle wound, was also not advanced to contact precautions. Interviews with nursing staff confirmed the oversight in precautionary measures, which contradicted the facility's MRSA policy. Additionally, infection control practices were not maintained during medication administration for a resident on COVID-19 precautions. An LPN failed to wipe off a nasal spray applicator after use and did not follow proper procedures for handling the nasal spray outside the precaution room. Interviews with staff revealed a lack of recent education on infection control practices, particularly regarding nasal spray administration in precaution rooms. The facility's policies did not address these specific infection control practices.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The provider failed to ensure that fourteen out of twenty-nine residents received a summary of their baseline care plan within 48 hours of admission. The records for residents 10, 23, 46, 49, 53, 55, 64, 65, 67, 70, 224, 274, 375, and 424 showed no documentation that a baseline care plan summary had been reviewed with the residents or their representatives. Additionally, the baseline care plan for resident 424 was not signed as completed until a later date, indicating a delay in the process. Interviews with staff revealed gaps in the implementation of baseline care plans. The social services designee admitted to not reviewing or providing a summary of the baseline care plan to residents or their representatives, citing insufficient training since assuming the position. The clinical care coordinator RN also acknowledged not documenting the review of the baseline care plan in the residents' electronic medical records (EMR). The facility's policy requires that a baseline care plan be started on the first day of admission and completed within 48 hours, which was not adhered to in these cases.
Failure to Provide Bed-Hold Notice During Hospital Transfers
Penalty
Summary
The provider failed to provide bed-hold notices to a resident and their representative during two out of three hospital transfers. The resident's electronic medical record indicated transfers to the hospital on three occasions. While the representative was notified of the bed-hold policy during the first transfer, there was no documentation of such notification for the subsequent transfers. An interview with the social service designee confirmed the absence of documentation for the latter two transfers. The facility's Bed Reserve Policy and Bed-Hold and Return Agreement require that residents or their representatives be informed of the bed-hold policy at admission and upon each transfer, allowing them to request a bed-hold by paying a daily rate.
Failure to Update Resident Care Plan for MRSA and Behavioral Interventions
Penalty
Summary
The provider failed to ensure the timely review and revision of a resident's care plan, specifically for a resident who was admitted with multiple wounds and later diagnosed with MRSA. The resident's care plan initially included Enhanced Barrier Precautions (EBP) due to her wounds, but after the MRSA diagnosis, the care plan was not updated to include contact precautions. Additionally, the care plan did not list Prevalon boots as an intervention for her wounds, despite their use being observed. The care plan also lacked focus areas, goals, or interventions addressing possible complications related to the resident's diagnosis of rhabdomyolysis. Furthermore, the resident had a history of barricading herself in her husband's room, which was noted in her nurse progress notes. However, the care plan did not include interventions for this behavior, nor did it address the use of family as an intervention, despite family being called multiple times to help calm her behaviors. The facility's policy requires individualized, resident-centered care planning to be maintained throughout the resident's stay, with updates reflecting current care needs as changes occur, which was not adhered to in this case.
Inadequate Pain Management for Resident
Penalty
Summary
The provider failed to ensure adequate pain management for a resident who expressed experiencing pain. The resident, who had a history of right-hand surgery, back pain from a fall, and multiple diagnoses including peripheral vascular disease and type 2 diabetes, reported pain on the left side of her body. Despite having an active physician order for Tramadol, a pain medication, the medication was not available on the medication cart, and the resident was informed by an LPN that no pain medication was available. The resident's care plan included interventions for pain management, such as providing analgesics as ordered and notifying the physician if pain relief was inadequate, but these were not effectively implemented. The deficiency was further highlighted by the lack of a written prescription for Tramadol being sent to the pharmacy, which delayed the medication's availability. Interviews with the DON and CCC confirmed that the pharmacy had not received the necessary prescription, and the CCC acknowledged that the provider should have followed up with the physician. Additionally, standing orders for pain control were not consistently entered into the resident's EMR upon admission. The facility's pain management policy outlined procedures for identifying and managing pain, but these were not adequately followed, resulting in the resident's pain not being addressed in a timely manner.
Failure to Monitor and Document Post-Dialysis Vital Signs
Penalty
Summary
The provider failed to ensure proper monitoring of a resident who required dialysis treatment, specifically in documenting vital signs post-dialysis. The resident, who had a dialysis port in his chest and received dialysis three times a week, had a care plan that required significant changes in pulse, respirations, and blood pressure to be reported immediately. However, the resident's electronic medical record showed discrepancies in the documentation of post-dialysis vital signs, with some entries using outdated data from previous dates instead of current readings. Interviews with the registered nurse and the director of nursing revealed that the process for documenting post-dialysis vital signs was not consistently followed. The nurse acknowledged that the vital signs should ideally be taken and documented each time the resident returned from dialysis, but this did not always occur. The director of nursing confirmed that the expectation was for vital signs to be obtained and documented each time, but this was not consistently done, leading to incomplete and inaccurate records for the resident's post-dialysis condition.
Kitchen Cleanliness Deficiency
Penalty
Summary
The provider failed to maintain cleanliness in the kitchen, specifically regarding the range hood vents, ice machine, and ceiling tiles. During an observation, the range hood vents were found to be covered with a greasy film and lint, while the ice machine had a layer of hard water scale build-up on its sides and embedded deposits between the cooling fan fins. Additionally, ceiling tiles above the refrigerator had dark water stains. Interviews revealed that the range hood was cleaned by a contracted service, but the dietary aide was unsure of the last cleaning date, and the range hood was not included in the weekly cleaning schedule. The dietary manager confirmed the lack of a cleaning schedule for the range hood and noted that maintenance was responsible for cleaning the vents, which had not been done recently. The maintenance director used a computer program to track maintenance tasks and stated that the range hood and vents were to be cleaned monthly, but the vents had not been cleaned in June. The ice machine, which had been moved from another area, was cleaned when the kitchen floor was replaced in May, but it was due for replacement. The maintenance director also acknowledged the need to replace the stained ceiling tiles, attributing the stains to condensation from the air conditioning duct. A review of the kitchen exhaust fan log showed that cleaning tasks were marked as completed from January to May 2024, and the provider's cleaning policy required the Food and Nutrition Services staff to maintain sanitation through compliance with written cleaning schedules.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 5 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Huron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie View Healthcare Center | 20.8 mi | ★★★★★ | 2 | 0 |
| Weskota Manor Inc | 24.9 mi | ★★★★★ | 3 | 0 |
| Good Samaritan Society De Smet | 33.7 mi | ★★★★★ | 3 | 0 |
| Avantara Redfield | 38.6 mi | ★★★★★ | 9 | 0 |
| Eastern Star Home Of South Dakota, Inc | 38.6 mi | ★★★★★ | 1 | 0 |
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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.