Below 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 Mountain View during CMS and state inspections, most recent first.
A resident with depression, vascular dementia, and adjustment disorder had repeated suicidal ideations documented in counseling and ED records, including statements about hanging himself with a call light cord, but the chart lacked documentation that these concerns were fully communicated or incorporated into the care plan. After a CNA found the resident with the call light cord around his neck, the RN did not promptly assess him, notify the on-call provider or representative, or ensure the event was handed off to the next shift, and the record lacked documentation of the checks and assessment after the incident.
Failure to Timely Report Abuse, Injury, Sexual Misconduct, and Suicide Attempt: Staff did not immediately report suspected abuse of a resident by a CNA, a resident’s report that a foot wound was caused by a bed frame, an off-duty LPN’s inappropriate relationship with a cognitively intact resident, and a resident’s suicide attempt involving a call light cord. The events involved delayed notification to DON, inconsistent staff accounts, and missed escalation of reportable incidents.
A resident with dementia, anxiety, and depression was verbally abused during shower care while a CNA used a personal phone to record a Snapchat video in the shower room. The resident said she was spoken to rudely, tried to stop the shower, and had her hands pulled off the grab bars while she begged the staff member to stop. Another staff member reported hearing the CNAs laughing and joking about the video, and one CNA had a prior discipline for taking and posting a resident photo on social media.
A resident with a left foot wound and infected diabetic ulcer had physician antibiotic orders entered incorrectly into the EMR by an RN. The IM antibiotic was entered with the wrong start date, causing the resident to miss the first dose, and the resident later required hospitalization and amputation of the left foot’s 5th toe.
A facility failed to complete trauma-informed care assessments and document individualized trauma history and triggers for two residents with mental health and trauma-related needs. One resident with depression, dementia, and a history of counseling for trauma, grief, and passive SI was found with a call light cord loosely around his neck, but staff did not promptly notify the oncoming nurse or provider and did not identify trauma triggers on his care plan. Another resident with severe cognitive impairment, depression, anxiety, and trauma-related counseling needs had a positive trauma screen, yet his care plan did not identify PTSD, trauma history, or triggers despite staff knowing he had trauma related to a prior MVC and the loss of his wife.
Non-compliance with F684 occurred when a resident was left without repositioning or continence care for about nine hours overnight due to an unupdated CNA assignment sheet and lack of hand-off communication during a split shift. Another resident, whose care plan required Cares in Pairs because of behavioral and safety concerns, was assisted with toileting by a single CNA, contrary to the documented intervention. In a separate event, a resident who activated a call light for incontinence care waited roughly one and a half to two hours before a CNA changed her brief, after the assigned CNA turned off the call light, returned to another room, and later dismissed reports of the resident hollering, leading another CNA to eventually provide the needed continence care.
A facility failed to follow physician orders and policy in several areas of resident care. Staff did not document physician notification after a resident refused dialysis treatments, a CMA documented lactulose as given before confirming the resident took it, an LPN did not fully deliver insulin and did not give Humalog at the ordered time, staff did not document each-shift checks of a resident’s WanderGuard after an elopement, and an LPN verified G-tube placement by auscultation instead of the ordered aspiration and pH check.
Failure to follow hand hygiene and glove use practices was observed during resident care. Two CNAs put on gowns and gloves without first performing hand hygiene before assisting a resident with a Hoyer lift and incontinence care, a wound care RN changed a resident’s sacral dressing and then put on new gloves without hand hygiene, and an LPN used the same gloved hands after cleaning a resident’s glasses to administer a G-tube feeding. The LPN also placed clean gloves directly on a resident’s bedding before checking another resident’s blood sugar.
Medication Left at Bedside Without Self-Administration Evaluation: A resident with dementia/Alzheimer’s disease and schizophrenia had lactulose left in a cup at the bedside for periodic sips, even though there was no order allowing bedside self-administration and no self-administration evaluation for that medication. The CMA did not know whether the resident had been assessed as safe to self-administer, and the DON confirmed the resident was not safe to self-administer her own medication.
Staff failed to keep resident PHI private when laptops on medication carts displayed residents' names, photos, MARs, and other identifying information in view of anyone passing by. An LPN acknowledged leaving a screen unlocked, and a CMA left MARs open while administering meds and eye drops, with resident information visible at the nurses' station and in the hallway.
The facility failed to adhere to professional standards in medication management, with nurses signing off on controlled substances counts prematurely and a resident self-administering an inhaler without proper assessment. Additionally, an RN documented medication administration before actually administering it, contrary to policy.
The facility failed to properly monitor residents returning from dialysis, as evidenced by inaccurate documentation of post-dialysis vital signs for three residents. A resident with end-stage renal disease reported inconsistencies in monitoring, and records showed discrepancies in vital sign documentation. Another resident also experienced inconsistent vital checks, with records showing outdated data. Staff interviews revealed flaws in the process, with pre-populated data not being updated, contrary to the facility's dialysis management policy.
The facility experienced a medication error rate of 18.75% due to improper administration of diclofenac sodium gel and Flonase nasal spray by staff, contrary to orders and policies. A resident's nebulizer treatment was documented but not administered, and Nystatin powder was given without a physician's order. The DON confirmed these discrepancies.
The facility failed to ensure proper labeling and storage of medications and medical supplies. A resident's Ativan prescription lacked a pharmacy label, preventing verification against the physician's order. Outdated medical supplies were found in storage rooms, and insulin pens for two residents were not labeled or dated correctly. Staff interviews revealed unclear responsibilities for managing outdated supplies, contributing to these deficiencies.
The facility failed to ensure proper cleaning of a whirlpool tub and adequate hand hygiene during medication administration. A CNA did not follow the posted cleaning instructions for the tub, and multiple staff members, including RNs and an LPN, did not perform hand hygiene as required by the facility's policy. Additionally, an RN did not adhere to proper hand hygiene while providing care to a resident with a yeast infection.
The facility failed to ensure care plans for two residents were updated and followed. One resident's care plan lacked specific interventions for manipulative behaviors, while another's inaccurately listed medication, leading to discrepancies in care. Staff interviews confirmed these issues, highlighting a need for accurate and timely care plan updates.
A resident with a history of multiple health issues was administered an antibiotic for a potential UTI without meeting clinical criteria. The facility failed to obtain a urinalysis and did not follow proper documentation and communication protocols. The infection preventionist incorrectly documented that microbiological criteria were met, and the facility's Antibiotic Stewardship Program policy was not followed.
A deficiency was identified when a resident was transported from a dialysis appointment on a facility-operated bus. The bus driver noticed the resident tilted backward in her wheelchair due to a malfunctioning front clamp strap, which failed to secure the wheelchair properly. This incident potentially placed the resident at risk for harm or injury.
A resident inflicted self-harm requiring surgery due to inadequate pain management. Despite having orders for pain medications, there was no documentation of administration, and pain levels were not properly assessed or managed. Staff interviews revealed inconsistencies in following pain management policies.
Failure to Provide Behavioral Health Care and Suicide Precaution Follow-Through
Penalty
Summary
The facility failed to ensure a resident with depression, vascular dementia with behavioral disturbance, and adjustment disorder with depressed mood received necessary behavioral health care and services after multiple suicidal statements and a suicide attempt involving a call light cord. The resident had been receiving counseling for depression, grief/loss, trauma history, anxiety, and depression, and counseling notes documented passive suicidal ideations on more than one occasion. A social service note also documented that the resident was unhappy with his situation and was having a hard time seeing the bright side of anything, but there was no documentation that the planned social service follow-up was completed. The resident also made suicidal statements during an emergency department evaluation, including that he would hang himself with a call light cord if he returned to the nursing facility. Psychiatry evaluated him, determined there was no indication for inpatient psychiatric admission, and completed a safety plan. However, the facility did not have documentation that it reviewed the full ED psychiatric records when the resident returned, and the resident’s chart did not contain documentation of the suicidal ideations from that ED visit. The resident’s care plan addressed depression and counseling for inappropriate behaviors, but it did not include interventions for suicidal ideations. On the night of the incident, a CNA found the resident with the call light cord wrapped around his neck. Accounts differed on whether the cord was loose or tight, but the CNA reported a red mark on the resident’s neck and removed the cord. The RN was notified, but did not assess the resident in the room, did not notify the on-call nurse, physician, or representative at the time, and did not ensure the event was communicated to the oncoming shift. The resident was not sent to the ED until the next morning, and the record lacked documentation of a skin assessment, the 15-to-30-minute checks that were reportedly done, and other progress notes related to the suicide attempt.
Failure to Timely Report Abuse, Injury, Sexual Misconduct, and Suicide Attempt
Penalty
Summary
The provider failed to timely report suspected abuse, neglect, theft, and other reportable incidents to the SD DOH after multiple events involving residents 2, 3, 4, and 5. The report identified that staff did not immediately report an allegation that CNA M was verbally rude and physically rough with resident 4, and the incident was not reported until about two weeks later. Resident 4 had been hospitalized for chronic medical issues unrelated to the incident and, on readmission, had no skin alterations noted on assessment and denied negative interactions with staff. The provider also failed to promptly report resident 3’s injury after he told WCN/RN E that his left outer foot wound was caused by scraping his foot against the metal frame of his bed. Resident 3 had been admitted to the hospital for an infected diabetic ulcer of the left outer foot, required surgical amputation of the left fifth toe, and later returned to the facility. The wound had first been documented as a blister, with nursing notes suggesting it may have occurred while putting on shoes, but the resident later stated the bed frame caused the injury. The wound was treated as usual and was not reported until the facility later reviewed the chart. The provider further failed to timely report a sexual relationship involving an off-duty LPN and resident 5, and failed to promptly report resident 2’s suicide attempt. Resident 5 had intact cognition with a BIMS score of 14 and was his own responsible party; multiple staff witnessed the LPN lying in bed with him, kissing, hugging, and engaging in other inappropriate touching, while other staff heard about or observed flirty behavior but did not report it. Resident 2 had a call light cord wrapped around his neck during the night, and staff gave inconsistent accounts of whether it was loose or tight; CNA Q said it was wrapped tightly enough to leave a red mark, while RN G did not assess him, did not notify management or the physician immediately, and later forgot to pass the event on until the next day. Resident 2 had prior documentation of passive suicidal ideations and later expressed suicidal intent in the ED, but the incident was not reported to the DON until many hours after it occurred.
Resident Dignity and Respect Not Protected During Shower Care
Penalty
Summary
The facility failed to protect a resident’s right to dignity and respect when a CNA used a personal phone to record a Snapchat video in the shower room while another CNA verbally abused the resident during bathing. The resident was admitted with diagnoses including dementia, anxiety, and depression, and her BIMS score was 14, indicating intact cognition. The resident later stated she remembered being in the shower room and being spoken to rudely by a staff member. She reported she did not want to take a shower, was holding the grab bars and tried to stand up, and the staff member told her to stop, then grabbed her hands and pulled them off the grab bars while she begged the staff member to stop. A restorative/rehab aide reported hearing that the CNA had taken a Snapchat video of the interaction between the other CNA and the resident, and that both CNAs were laughing and making jokes about it. The aide notified the DON and administrator. The resident said she did not recall any video being taken and had not experienced further problems during showers. The CNA involved in the video was previously disciplined for taking a picture of a resident and posting it on social media, and both CNAs were current on abuse prevention, resident rights, and HIPAA training at the time of the incident.
Incorrect Entry of Antibiotic Order Delayed Treatment
Penalty
Summary
The nursing facility failed to ensure a physician’s antibiotic order was accurately entered into the resident’s EMR by an RN. Resident 3 had a left foot wound that was assessed by the physician, who ordered an oral antibiotic, an IM antibiotic, and that the staff outline the area of redness on the left foot for monitoring. The oral antibiotic was entered to be administered on the same day it was ordered, but the IM antibiotic was entered with a start date of the following day, which did not match the physician’s order. Resident 3 had an infected diabetic ulcer on the left outer foot and was later hospitalized for surgical intervention, including amputation of the left foot’s 5th toe. The RN stated she printed the antibiotic orders and entered them into the EMR, knew both antibiotics were ordered for the same day, and later realized the resident did not receive the IM antibiotic because the order date had been entered incorrectly. The physician expected orders to be entered correctly and medications to be given according to the order, and the DON expected physician orders to be entered as written.
Failure to provide trauma-informed care and document trauma triggers
Penalty
Summary
The provider failed to identify and implement individualized trauma-informed and culturally competent care approaches for two residents with mental health and trauma histories. The facility’s policy stated that residents were to be assessed to determine if services were needed and that the care plan should address individualized emotional and psychosocial needs. However, the record showed that trauma-informed care assessments were not completed as expected, and trauma history and triggers were not identified or documented in the care plan for the residents involved. One resident had diagnoses including depression, vascular dementia with behavioral disturbance, and adjustment disorder with depressed mood, and was receiving fluoxetine, trazodone, and Wellbutrin XL. His behavioral health counseling notes documented referral for depression symptoms, grief/loss, a history of traumas, adjustment disorder, anxiety, and depression, with passive suicidal ideations noted on screening and ongoing moderate depression, blunted affect, emotional withdrawal, anger, helplessness, irritability, and negative thinking. After a call light cord was found loosely wrapped around his neck, staff removed it and placed it on the bed enabler bar, but the oncoming day shift nurse was not notified, the provider was not notified until later, and the resident would not answer questions about the event. Social services staff stated they were unaware he was referred for past traumas and did not identify any trauma history or triggers on his care plan. A second resident had severe cognitive impairment, depression, anxiety, insomnia, and cognitive communication deficit, and he reported trauma related to losing his wife and had served in the Korean War. His care plan addressed depression and adjustment to loss, but did not identify PTSD, trauma history, or triggers. He had begun counseling for trauma-related issues, and the counseling note documented a positive trauma screen with current emotional symptoms and a goal to examine the relationship between emotions and triggers. Social services staff stated they were expected to review counseling notes and could contact the counselor for more information, but the trauma history was not identified on the care plan as expected.
Failure to Provide Timely Repositioning, Continence Care, and Care Plan–Directed Assistance
Penalty
Summary
Non-compliance with F684 occurred when one resident was not repositioned or provided continence care for approximately nine hours during an overnight shift. Camera footage confirmed that between 8:30 p.m. and 5:41 a.m., the resident did not receive repositioning or incontinence care. The facility’s investigation identified that the staff assignment sheet had not been updated to reflect that two CNAs were splitting the overnight shift, and there was no hand-off communication between the CNAs when one left and the other began the split shift. As a result, the resident’s routine checks and care needs were not carried out during that time period. Additional non-compliance involved another resident whose care plan required "Cares in Pairs," meaning two staff were expected to be present when providing care due to the resident’s history of manipulative behavior, verbal abuse toward staff, recording staff without their knowledge or permission, and making false accusations or statements about staff. Despite this care plan intervention, a CNA assisted the resident with toileting alone, without a second staff member present. The incident was discovered during the investigation of an unrelated event, and there were no adverse consequences reported as a result of this failure. The resident was observed later receiving assistance from two CNAs and reported satisfaction with her care and caregivers. A third incident of non-compliance occurred when a resident who was assigned to a CNA activated her call light for incontinence care and experienced a significant delay before her brief was changed. At the time the call light was activated, the assigned CNA exited another resident’s room, entered the resident’s room, turned off the call light, and then returned to the previous room instead of providing care. Later, the CNA was approached by a family member of another resident and appeared to respond to that request. More than an hour after the initial call light activation, the resident was heard hollering from her room. Another CNA informed the assigned CNA, who dismissed the hollering as the resident wanting her dinner tray removed. A different CNA was then asked to check on the resident and found that the resident had a bowel movement coming out of her brief, with fecal matter on the bedding that appeared to have been present for some time. The resident later confirmed she had soiled her brief and that it took approximately one and a half to two hours before a CNA came to change her. Across these three events, the deficiencies centered on failures to provide timely and appropriate care according to orders, care plans, and residents’ needs and preferences. In the first case, lack of updated assignments and hand-off communication led to missed repositioning and continence care. In the second, a CNA did not follow a clearly documented care plan requiring two staff for care. In the third, the assigned CNA did not respond to a resident’s call light and vocal requests for incontinence care in a timely manner, resulting in prolonged exposure to soiled conditions, even though the resident reported that her care was usually provided promptly and that this was an isolated event.
Failure to Follow Orders for Dialysis Notification, Medication Administration, Elopement Monitoring, and G-Tube Verification
Penalty
Summary
The nursing facility failed to ensure staff followed professional standards of practice in multiple areas of resident care. One resident with end-stage renal disease, chronic kidney disease stage 5, renal dialysis, type 2 diabetes, and edema refused dialysis treatments on four occasions, but the record did not show that the physician was notified of those refusals. The resident’s dialysis assessment forms were initiated for several treatment dates, but they were not completed and did not show physician notification. Staff interviews confirmed they expected physician notification when a resident refused dialysis, and the DON confirmed there was no documentation that the physician had been notified. The facility also failed to ensure medications were administered and documented according to physician orders. For one resident, a CMA documented lactulose as administered even though she had left the medication at the bedside and knew the resident had not yet taken it. Another CMA described a practice of giving a resident MiriLAX mixed with water in portions and documenting it as administered before confirming the full dose had been taken. For another resident, an LPN administered Humalog and scheduled insulin but did not keep the insulin pen button pressed long enough to ensure the full dose was delivered, and she also did not follow the order to give Humalog before breakfast. The LPN acknowledged the injection time was too short and that this was a medication error. The facility further failed to document required monitoring for an elopement device and did not follow the tube-feeding placement verification process. After a resident with moderate cognitive impairment eloped from the facility and was later returned, a WanderGuard was placed on his ankle with an order to ensure placement every shift, but the MARs did not show that staff checked the device each shift or verified that it was functioning. In addition, for a resident with a G-tube, an LPN checked placement by auscultating air into the tube with a stethoscope and then administered formula, even though the facility policy required aspiration of gastric contents and pH confirmation before use. The DON and administrator stated they expected staff to follow the physician’s orders and the facility policies for tube placement verification.
Failure to Follow Hand Hygiene and Glove Use Practices
Penalty
Summary
The provider failed to ensure staff followed infection prevention and control practices during multiple resident care activities. For resident 2, who had a sacral wound and physician’s orders for dressing changes twice daily, two CNAs arrived with a Hoyer lift and put on gowns and gloves without first performing hand hygiene before assisting with incontinence care. Later, a wound care RN performed a dressing change on the resident’s sacral wound, removed her gloves after cleaning the wound, stated there was no hand sanitizer in the room, and then put on a new pair of gloves without first performing hand hygiene before placing the dressing. For resident 5, who had a G-tube for medications, fluids, or nutrition, an LPN removed the resident’s glasses, washed them with a paper towel and water, and then used the same gloved hands to administer nutritional formula through the feeding tube without changing gloves or performing hand hygiene. For resident 57, the same LPN placed a clean pair of gloves directly on top of the resident’s bedding without a barrier before checking the resident’s blood sugar. The DON stated staff were expected to perform hand hygiene before putting on gloves and PPE, and agreed the LPN should have completed hand hygiene and put on new gloves after cleaning resident 5’s glasses and before administering the tube feeding.
Medication Left at Bedside Without Self-Administration Evaluation
Penalty
Summary
The provider failed to ensure that a resident was evaluated for the ability to safely self-administer lactulose before the medication was left at the bedside. During an observation, a CMA administered the resident’s eye drops and then reminded the resident to drink the clear liquid in a plastic cup on the bedside table, stating that the cup contained lactulose and that it had been left there earlier during the medication pass so the resident could take periodic sips because the medication was not pleasant tasting. The lactulose had been left at the bedside even though there was no order for bedside self-administration. Record review showed the resident had a physician’s order for lactulose three times per week, and the resident had previously been evaluated for self-administration of melatonin and found not safe to self-administer due to dementia/Alzheimer’s disease and schizophrenia. There was no self-administration evaluation for lactulose. The CMA later stated she did not know whether the resident had been evaluated or deemed safe to have lactulose left at the bedside, and the DON confirmed the resident was not safe to self-administer her own medication and that the CMA was expected to observe the resident consume the lactulose in its entirety before leaving the room and documenting it as administered.
Resident PHI Left Visible on Open EMR Screens
Penalty
Summary
Staff failed to protect residents' privacy and the confidentiality of protected health information displayed in the facility's electronic medical records. On 1/4/2026 at 9:45 a.m., a laptop computer on top of the medication cart in front of the first-floor nurses' station displayed a list of residents' full names, photographs, and other identifying information, and the screen was visible to anyone passing by the cart. Later that morning, the same medication cart computer was open to resident 2's MAR while CMA L administered medications; after resident 2 spat out a medication, CMA L returned to the cart, discarded it, prepared another dose, and then closed the screen before returning to the resident. At 11:40 a.m., CMA L prepared resident 34's eye drops at the medication cart while leaving the MAR open on the screen, then walked to the resident's room to administer the drops, returned to the cart to document the administration, reviewed the open MAR, prepared additional scheduled medications, and only then closed the screen before leaving the cart. On 1/5/2026 at 1:16 p.m., an open computer on the medication cart displayed resident 88's information while no employees were in the hallway for about three minutes. LPN H stated she was the last person to use the computer, did not lock the screen, and acknowledged that resident information was visible to anyone passing by and that someone could access and document in the facility's computer system under her name if the screen was not locked. The administrator stated staff were expected to maintain privacy of resident information and agreed documentation could be accessed or changed if the computer screen was not locked.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The report identifies deficiencies in the handling and documentation of controlled medications by nursing staff at the facility. Specifically, it was observed that a registered nurse (RN) and two licensed practical nurses (LPNs) signed the controlled substances count sheet as the offgoing nurse before their shifts had ended and before completing the required medication count with the oncoming nurse. This action was contrary to the facility's policy, which mandates that both the oncoming and offgoing nurses complete and verify the accounting of all controlled medications together at each shift change. Additionally, the report highlights a failure in the assessment and documentation process for a resident self-administering medication. A resident with moderate cognitive impairment and a diagnosis of dementia was observed self-administering an inhaler without prior documented assessments to determine the appropriateness and safety of self-administration. The facility's policy requires an evaluation of the resident's cognitive, physical, and visual ability to self-administer medications, which was not completed until after the resident was observed using the inhaler. Furthermore, the report notes an instance where an RN documented the administration of medications before actually administering them to a resident. This practice was against the facility's medication administration policy, which requires that the administration be recorded immediately after the medication is given. The director of nursing confirmed the expectation that medications should be administered before being documented as given.
Inadequate Monitoring of Post-Dialysis Residents
Penalty
Summary
The facility failed to ensure proper monitoring of residents returning from dialysis treatments, as evidenced by the lack of timely and accurate documentation of post-dialysis vital signs for three residents. Resident 26, who has end-stage renal disease and other significant health conditions, reported inconsistencies in receiving assistance and monitoring upon returning from dialysis. Her electronic medical record showed discrepancies in the dates of recorded vital signs, indicating that the documented post-dialysis vitals were not taken on the actual day of her return from dialysis. Similarly, Resident 33, who also requires regular dialysis, reported that her vital signs were not consistently checked upon her return, and her records showed similar issues with the documentation of vital signs from previous days being used instead of current data. Resident 85, who has multiple health issues including end-stage renal disease and orthostatic hypotension, also had discrepancies in the documentation of his post-dialysis vital signs. Interviews with staff, including a registered nurse and the director of nursing, revealed that the process for recording post-dialysis assessments was flawed, with pre-populated data from previous assessments not being updated with current information. The facility's policy on dialysis management was not adhered to, as it required the review and documentation of post-dialysis information upon the residents' return, which was not consistently done.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The provider failed to ensure proper medication administration, resulting in a medication error rate of 18.75%. Observations revealed that RN G and UMA K did not use the measurement device for diclofenac sodium 1% gel, leading to incorrect dosing for three residents. Additionally, RN I administered Flonase nasal spray in excess of the physician's order for one resident. These actions were contrary to the provider's medication administration policy and the manufacturer's recommendations. Another deficiency was noted when a resident's nebulizer treatment was documented as administered, but the resident reported not receiving it. The nebulizer medicine cup was found with clear liquid, indicating the treatment had not been given. The DON confirmed the resident's statement and acknowledged the discrepancy between the documentation and the actual administration. Furthermore, RN N applied Nystatin powder to a resident without a current physician's order. The resident had a severe yeast infection, and the medication was administered without proper documentation in the electronic medical record. The DON confirmed that all medications should have a current physician's order before administration, which was not adhered to in this case.
Deficiencies in Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and medical supplies, leading to several deficiencies. One resident's prescription for Ativan, an anti-anxiety medication, was not accurately labeled, as the medication bottle lacked a pharmacy label to confirm the resident's identity, dosage information, or instructions for use. This oversight prevented nursing staff from verifying the medication against the physician's order before administration. Additionally, outdated medical supplies, including Ambu bags and hypodermic safety needles, were found in the medication storage rooms, indicating a lapse in the removal of expired items. Further deficiencies were noted with insulin pens for two residents, which were not labeled with pharmacy labels to confirm the identity of the medication, dosage, or usage instructions. The insulin pens were also not dated with the opening date, and staff were unable to locate information on the expiration period after opening. The facility's policy on medication storage did not address the disposal of outdated medical supplies, contributing to the oversight. Interviews with staff revealed a lack of clear responsibility for checking and removing outdated medical supplies, further highlighting the deficiencies in medication and supply management.
Inadequate Infection Control Practices
Penalty
Summary
The provider failed to ensure proper cleaning of the whirlpool (WP) tub by a certified nursing assistant (CNA) who was temporarily assisting with bathing residents. The CNA did not follow the posted cleaning instructions, which required running disinfectant through the aerator holes/jets and allowing the area to stand for at least 10 minutes. Instead, the CNA used a simplified cleaning process that did not meet the facility's standards, as confirmed by the director of nursing (DON). Additionally, there were multiple instances of improper hand hygiene during medication administration by four staff members, including registered nurses (RN), a licensed practical nurse (LPN), and an unlicensed medication aide (UMA). These staff members failed to perform hand hygiene before and after administering medications to residents, and in some cases, did not follow contact precautions for residents on isolation. The facility's hand hygiene policy, which emphasizes handwashing as a primary means to prevent infection spread, was not adhered to during these observations. One resident with a yeast infection was observed receiving personal care from an RN who did not follow proper hand hygiene protocols. The RN washed her hands for only a few seconds between glove changes and did not wash her hands at all before applying clean gloves at one point. This was contrary to the facility's hand hygiene policy, which requires at least 20 seconds of handwashing. The DON confirmed that the expectation was for staff to follow the hand hygiene policy, which was not met in these instances.
Failure to Update and Follow Care Plans for Two Residents
Penalty
Summary
The provider failed to ensure that the care plans for two residents were followed, updated, and revised promptly to reflect their current status and care needs. For Resident 26, interviews with staff revealed that the resident had manipulative behaviors and false accusations, but the care plan lacked specific non-pharmacological interventions to address these behaviors. The social service director acknowledged that the interventions were not listed, and the process to review and update care plans was interdisciplinary. Additionally, the care plan indicated that personal care should be provided with two staff members present, but there was no evidence that this intervention was consistently documented or followed. For Resident 51, the care plan inaccurately reflected that the resident was taking Plavix, an antiplatelet medication, when in fact, the resident was prescribed Eliquis, a blood thinner that requires different monitoring. Interviews with nursing staff confirmed the discrepancy, and the director of nursing noted that medications were not typically specified on care plans due to potential changes. However, the expectation was for care plans to be updated as the resident's care and needs changed. The facility's care plan policy emphasized the importance of individualized, resident-centered care planning and the need for care plans to be updated to reflect current care needs.
Failure to Ensure Clinical Criteria for Antibiotic Use in Suspected UTI
Penalty
Summary
The provider failed to ensure that a resident who received an antibiotic for a potential urinary tract infection (UTI) met the clinical criteria for its use. The resident, who had a history of diabetes, peripheral vascular disease, depression, insomnia, and anorexia, was reported to have mood changes, low appetite, and dysuria. A medical provider ordered a urinalysis (UA) and started the resident on cefdinir, an antibiotic, for a potential UTI. However, the UA was not obtained, and the antibiotic was administered without confirming the UTI diagnosis through appropriate clinical assessment or microbiological evidence. Interviews with facility staff revealed that the expected documentation and communication protocols were not followed. A Suspected UTI SBAR form, which should have been completed by the nurse, was not found at the second-floor nurses' station. Additionally, there was no documentation explaining why the UA was not obtained, whether further attempts were made to collect the urine sample, or if the medical provider was informed of the inability to obtain the UA. The infection preventionist incorrectly documented that microbiological criteria were met, despite the lack of a UA. The facility's Antibiotic Stewardship Program policy emphasizes the importance of appropriate antibiotic use, which was not adhered to in this case.
Deficiency in Wheelchair Securement on Facility Bus
Penalty
Summary
A deficiency was identified when a resident was being transported from a dialysis appointment to the facility on one of the provider's buses. During the transport, the bus driver noticed through the rear-view mirror that the resident was tilted backward in her wheelchair. Upon further assessment, it was discovered that one of the front clamp straps used to secure the wheelchair was extended, indicating a malfunction. The tie-down system, which is designed to automatically tighten when the strap loosens due to normal bus movements, failed to function as intended. This malfunction in the tie-down system potentially placed the resident at risk for harm or injury. The incident highlights a failure in ensuring that the wheelchair was safely secured during transport, which is a critical aspect of resident safety. The deficiency was identified through a review of the facility-reported incidents, interviews, and record and policy reviews conducted by the South Dakota Department of Health.
Inadequate Pain Management Leading to Resident Self-Harm
Penalty
Summary
The provider failed to ensure adequate pain management for a resident who inflicted self-harm that required surgical treatment. The resident, who was cognitively intact and had no signs of depression, inflicted a stab wound to his abdomen and was transferred to the hospital for surgery. The incident revealed non-compliance in the pain management process, including inadequate pain documentation, failure to document the administration of pain medication, and incomplete pain assessments. The resident had multiple diagnoses, including rheumatoid arthritis and other conditions that could cause pain. Despite having physician orders for various pain medications, there was no documentation that Tylenol, which was ordered as needed for pain, had been administered. The resident's pain levels were documented as high on several occasions, but there was no evidence that any interventions were provided to relieve his pain. Interviews with staff revealed inconsistencies in the pain management process. The admitting nurse failed to enter standing orders for pain medication into the electronic medical record, and there was a lack of documentation of pain assessments and interventions. The provider's policies on pain management and following physician orders were not adequately followed, contributing to the resident's unmanaged pain and subsequent self-harm.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 56 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rapid City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Saint Cloud | 1.1 mi | ★★★★★ | 6 | 0 |
| Avantara Arrowhead | 1.5 mi | ★★★★★ | 20 | 0 |
| Clarkson Health Care | 1.8 mi | ★★★★★ | 1 | 0 |
| Fountain Springs Healthcare | 1.9 mi | ★★★★★ | 11 | 0 |
| Avantara North | 1.9 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avantara Mountain View.
100% money-back within 48 hours.
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.