Average — CMS composite of the measures below.
The next survey window likely opens around January 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 North during CMS and state inspections, most recent first.
Respiratory care was not provided safely when oxygen tubing and nasal cannulas for several residents were found on the floor, draped over a bed, wrapped around a bedrail, or not dated, and one resident’s nebulizer mask and tubing were left uncovered with liquid still in the chamber. Staff and the IP acknowledged the equipment was not being stored, cleaned, or documented according to policy, and one resident’s cannula had no order or record showing when it was last changed.
A resident receiving lidocaine for oral pain had a MAR and medication label that did not specify a dose amount for each application. One RN routinely poured about 5 mL into a cup and applied it with a cotton swab, while another RN gave the medication without measuring the dose and used less than the box’s usual adult amount. The DON, ADON, and administrator acknowledged the missing dosage information and that dosage is one of the five rights of medication administration.
A resident with a urinary catheter did not have a physician's order, documented clinical indication, or a removal plan during their stay. Nursing assessments failed to identify the catheter or document related care needs, and there was no communication about a possible UTI or urine sample at discharge. The receiving facility found the catheter with significant sediment and treated the resident for a UTI.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident was discharged to another facility without proper documentation or communication of essential care information. The discharge summary was incomplete, missing key details about the resident's medical status, recent lab results, and care needs. Required sections of the discharge assessment were not completed or signed, and no staff member was designated to ensure discharge planning in the absence of a social services designee.
A resident with chronic respiratory failure and a physician's order for continuous oxygen was discharged and transported to another facility without documented arrangements for oxygen during transit. The RN responsible for discharge could not confirm if portable oxygen was provided or if a hand-off report was given, and facility policy requiring staff to ensure adequate portable oxygen was not followed.
A staff member who had completed a practical nursing degree was allowed to work as a nurse after her temporary license became invalid due to failing the NCLEX. Despite reporting to management that she had passed the exam, she did not provide proof of a permanent license, and her status was not verified until months later. The staff member also provided a falsified license screenshot when questioned.
The provider failed to serve meals at safe and appetizing temperatures during two meal services. Pizza was repeatedly reheated but did not reach the required temperature before serving, and food items were left uncovered, resulting in dryness. The CDM acknowledged the need for better temperature maintenance and covering of food.
During a respiratory outbreak, a facility failed to adhere to infection control practices. An LPN did not wear a mask, and CNAs did not follow Enhanced Barrier Precautions (EBP) while providing care. Shared equipment was not cleaned, and a resident's colostomy rinsing container was improperly stored. An RN was unaware of gown requirements for residents on EBP, and PPE was not used during vital sign checks. These actions violated the facility's infection prevention policies.
A COTA failed to provide adequate assistance and interaction to a resident during breakfast, leaving the meal mostly uneaten and cold. Additionally, a resident's colostomy rinsing container was left in full view, compromising privacy and dignity. These actions violated the facility's standards of care and dignity policies.
A resident with cognitive impairment had a dignity curtain in her room to protect her privacy due to disrobing behavior. However, the facility failed to document the frequency of this behavior, which was necessary to justify the curtain's use. Despite interventions in the care plan to monitor such behaviors, the facility's records did not reflect the resident's disrobing, and staff provided inconsistent reports on its frequency.
A resident with cognitive impairment and a history of care refusal was inappropriately restrained by two CNAs and an LPN during personal care. The resident, who had been refusing care more frequently after the death of his spouse, became combative when staff attempted to change him. Despite knowing it was wrong, the CNAs followed the LPN's instructions to restrain the resident's lower extremities. The facility's protocol for managing care refusals was not followed, leading to the deficiency.
A resident with severe cognitive impairment left the facility without staff knowledge and was not properly assessed upon return. Another resident, also with severe cognitive impairment, was left unattended in her wheelchair and found on the floor. Both incidents highlight failures in supervision and adherence to care plans.
A resident eloped from the facility and was found by a passerby 125 yards away. The RN failed to notify management immediately, leading to a delay in reporting the incident to the SD DOH beyond the required timeframe.
Respiratory equipment not properly stored, dated, or cleaned
Penalty
Summary
Safe and appropriate respiratory care was not provided when oxygen tubing and nasal cannulas were observed improperly stored and not dated for multiple residents who used oxygen. For one resident, oxygen tubing and a nasal cannula were found lying on the floor in the room, later wrapped around the bedrail, and the infection preventionist stated this did not meet the expectation that the equipment be stored in a plastic bag when not in use. For another resident, oxygen tubing and a nasal cannula were draped across the bed and later lying on the floor. For a third resident, the nasal cannula attached to the oxygen concentrator had no date on the tubing, and the resident’s record did not contain an order to change the cannula tubing. A fourth resident had both portable and concentrator oxygen tubing and nasal cannulas dated 12/28, and the resident also used a nebulizer machine three times per day. The nebulizer mask and tubing were observed on the nightstand with liquid remaining in the medication chamber, and the mask was lying uncovered directly on the nightstand. The resident stated that some staff rinsed and dried the nebulizer mask between treatments, but others did not, and the infection preventionist acknowledged the nebulizer was not being cleaned and stored according to policy. Staff interviews confirmed that residents with oxygen were expected to have nasal cannulas and tubing changed weekly, with the date documented, and that the resident without a physician order had no indication of when the cannula was last changed. The director of nursing and assistant director of nursing agreed that the respiratory equipment was not being properly stored and cleaned according to policy, and that the lack of dating and documentation left it unknown how old one resident’s nasal cannula was.
Missing Lidocaine Dose Amount Led to Improper Medication Administration
Penalty
Summary
The nursing facility failed to ensure professional standards of quality were met for a resident receiving lidocaine for oral pain because the physician order and MAR did not include a dose amount for each application. Resident 64 had a history of dental extractions on 11/6/25 and later developed swelling and a white pustule along the upper left gum line, leading to a change from lidocaine ointment 5% to viscous lidocaine 2% for oral use. The revised order directed staff to apply one application to the mucous membrane three times daily before meals, but the medication label and MAR did not specify how much lidocaine to administer per dose. During observation, RN E prepared the medication by pouring about 5 mL into a medication cup and using a cotton-tipped applicator to apply it to the resident’s gums, stating this was her usual method. RN F later acknowledged she did not measure the dose before giving the medication and used less than the amount listed on the box, which stated the usual adult dosage was 15 mL. The DON, ADON, and administrator all acknowledged that the resident did not have a dosage amount listed and that dosage is one of the five rights of medication administration; the administrator also stated staff should have contacted the provider for clarification when a medication lacked a dosage amount.
Failure to Ensure Proper Catheter Management and Documentation
Penalty
Summary
The facility failed to ensure proper management and documentation of a urinary catheter for a resident during their stay. Upon admission, neither the hospital discharge orders nor the facility's admission orders included documentation of a urinary catheter, despite the resident having one in place as noted in the nurse admission assessment. There was no physician's order for the catheter, no documented clinical indication for its use, and no plan for its removal when no longer clinically indicated. Daily nursing assessments from 6/14 to 6/17 did not identify the presence of the catheter or document any related care needs or signs of urinary tract infection (UTI). On 6/16, staff noted abnormal urine characteristics and notified the medical provider, who ordered a urinalysis, but the results were not available at the time of the resident's discharge. When the resident was transferred to another facility, the catheter was found to have significant sediment, and there was no communication from the discharging facility regarding a possible UTI or that a urine sample had been obtained. The receiving facility subsequently removed the catheter and started the resident on antibiotics for a UTI. Interviews with facility staff confirmed that required processes for catheter management, including obtaining physician orders, documenting medical necessity, and planning for removal, were not followed. The facility's own CAUTI prevention guidelines were not adhered to, contributing to the deficiency.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Failure to Document and Communicate Discharge Information
Penalty
Summary
The provider failed to follow its own policy to ensure that a resident's discharge plan was properly documented and that appropriate information was communicated to the receiving nursing home. Specifically, there was no documentation to support that any referral information or discharge planning communication was sent to the facility that accepted the resident for admission. The resident's closed electronic medical record lacked progress notes indicating communication with the receiving facility, and the required Instruction and Summary for Discharge assessment was incomplete. Key sections of the assessment, such as the summary of the resident's status and rehabilitative services, were either not completed or unsigned, and the medical provider's signature was missing. The resident involved had multiple care needs at the time of discharge, including a Foley catheter, recent signs and symptoms of a possible urinary tract infection with pending lab results, a physician's order for continuous oxygen, use of a wheelchair cushion and low-air-loss mattress, and a recent course of Vancomycin for C. difficile. The documentation failed to include important resident-specific information such as recent COVID testing results, nurse assessments for COVID-19 symptoms, and updated wound care information. The absence of a social services designee at the time of discharge meant that no other staff member was identified to assume responsibility for discharge planning, resulting in incomplete and insufficient information being provided to the receiving facility.
Failure to Provide Physician-Ordered Oxygen During Resident Transfer
Penalty
Summary
A resident with a diagnosis of chronic respiratory failure with hypoxia had a physician's order for three liters of continuous oxygen via nasal cannula. Upon discharge, the resident was transferred to another nursing facility approximately 100 miles away using a public transportation service. There was no documentation to show that arrangements were made to provide the resident with continuous oxygen during transport, as ordered by the physician. The registered nurse responsible for the discharge was unsure if the resident had portable oxygen at the time of discharge and could not confirm if a hand-off report was given to the receiving facility. The director of nursing and assistant director of nursing stated it was the discharging nurse's responsibility to ensure portable oxygen was available for the resident during transport, and if the receiving facility did not provide it, the sending facility should have supplied it. The facility's policy required staff to ensure portable oxygen tanks had adequate volume, but there was no evidence this was followed.
Failure to Validate Nursing License Status for Staff Member
Penalty
Summary
The facility failed to validate the nursing license status of a social services designee (SSD) who was employed as a nurse after completing her practical nursing degree. The SSD was issued a temporary nursing license and began working as a floor nurse, primarily on evening shifts, alongside two other licensed nurses. Although the SSD reported to management that she had passed the NCLEX exam, which would have resulted in a permanent nursing license, she was unable to provide documentation of this license when requested by the Human Resources (HR) director. Multiple requests for the license went unfulfilled, prompting further investigation by the Director of Nursing (DON), who was unable to verify the SSD's license status on the South Dakota Board of Nursing (SD BON) website. Subsequent communication with the SD BON confirmed that the SSD had failed the NCLEX, rendering her temporary nursing license invalid as of the date of the failed exam. Despite this, the SSD continued to work in a nursing capacity for several months. The SSD later provided a falsified screenshot of a temporary nursing license with altered dates. The facility's failure to verify the SSD's licensure status allowed her to work as a nurse without a valid license, constituting non-compliance with regulatory requirements for ensuring staff have appropriate and current credentials.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The provider failed to ensure that residents' meals were served at a safe and appetizing temperature during two observed meal services. During the evening meal service, pizza was removed from the oven and repeatedly failed to reach the required internal temperature of 165 degrees Fahrenheit. The pizza was initially measured at 132 degrees Fahrenheit and, despite multiple attempts to reheat it, only reached 162 degrees Fahrenheit before being served. Additionally, the pizza was left on a steam table where it cooled to 106 degrees Fahrenheit and appeared dry. The certified dietary manager (CDM) noted that the pizza should have been placed on a perforated pan to maintain its temperature. During the breakfast meal service, food items such as Cream of Wheat cereal, sausage gravy, and pureed foods were left uncovered on the steam table, resulting in a dry film forming on the food. Although the temperatures of the food remained acceptable, the lack of covering led to a decrease in the food's palatability. The CDM acknowledged that covering the food would have helped retain moisture and prevent cross-contamination. The provider's policy indicated that food temperatures should be maintained at acceptable levels, and if not, appropriate menu substitutions should be made.
Infection Control Deficiencies During Respiratory Outbreak
Penalty
Summary
The facility failed to implement effective infection prevention and control practices during a respiratory outbreak. An LPN was observed not wearing a mask while the facility was under outbreak status, despite a notice requiring mask use. The LPN interacted with a resident without a mask and only donned one after leaving the nurses' station, without performing hand hygiene. This lapse occurred despite the facility's policy requiring mask use and hand hygiene during an outbreak. Enhanced Barrier Precautions (EBP) were not consistently followed by staff. A CNA did not use gowns or gloves while providing personal care to a resident on EBP, incorrectly believing they were only necessary when emptying a catheter bag. Additionally, shared equipment such as a mechanical lift was not cleaned after use by CNAs, contrary to the facility's policy. Another CNA failed to change gloves and perform hand hygiene during personal care, leading to potential cross-contamination. Further deficiencies were noted in the handling of residents on EBP. An RN did not wear a gown while administering enteral nutrition to a resident with a feeding tube, unaware of the requirement. A CNA also failed to use PPE while obtaining vital signs from a resident on EBP. Additionally, a resident's colostomy rinsing container was improperly stored on a bedside table, posing an infection control issue. These actions were inconsistent with the facility's infection prevention policies, which aim to reduce the risk of infection transmission.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The provider failed to protect the residents' right to be cared for with respect and dignity, as evidenced by two specific incidents. In the first incident, a certified occupational therapy assistant (COTA) was observed neglecting a resident during breakfast. The resident, who had occupational therapy goals to improve self-feeding abilities, was left mostly unattended by the COTA, who was preoccupied with a cell phone and did not provide adequate assistance or interaction. The resident's meal remained mostly uneaten and cold, indicating a lack of proper care and attention. The COTA admitted to not making eye contact and using a derogatory term to describe the resident, which was against the facility's standards of care. In the second incident, a resident's colostomy rinsing container was left in full view on the bedside table, which was considered a dignity issue by the infection preventionist. This was observed on multiple occasions, including during the resident's breakfast, suggesting a disregard for the resident's privacy and dignity. The facility's policy emphasized the importance of maintaining resident privacy and dignity, which was not upheld in these instances.
Failure to Document Resident's Disrobing Behavior
Penalty
Summary
The provider failed to document a resident's disrobing behavior, which was necessary to support the continued use of a dignity curtain in her room. The resident, who had a history of brain injury resulting in cognitive impairment, was observed in her room with a dignity curtain placed to prevent others from seeing her if she disrobed. Interviews with registered nurses and the facility's administrator and director of nursing revealed that the dignity curtain was used to protect the resident's privacy due to her disrobing behavior, but there was no tracking of the frequency of this behavior. The resident's care plan included interventions to monitor and record occurrences of target behaviors, including disrobing, but the facility's documentation did not reflect this. The electronic medical record and behavioral progress notes did not mention the resident's disrobing behavior, and it was not listed as a targeted behavior in recent assessments and reviews. Interviews with staff indicated that the frequency of disrobing had decreased, but there was inconsistency in the reported frequency of the behavior. The facility's policy required that residents receiving psychotropic medication have their target behaviors monitored and recorded, but the lack of documentation did not support the continued need for the dignity curtain. The facility's evaluation form for the dignity curtain was intended to ensure it was not used as a seclusionary device, but the absence of behavioral documentation undermined this purpose.
Inappropriate Use of Physical Restraint on Resident
Penalty
Summary
A deficiency was identified in a long-term care facility involving the inappropriate use of physical restraint on a resident. The incident involved a resident with vascular dementia, anxiety, depression, and pain, who was on hospice care and had a moderate cognitive impairment. The resident had a history of refusing personal care, which escalated after the passing of his spouse. On the day of the incident, the resident refused to be changed, and when staff attempted to change him, he became combative. Two CNAs and an LPN physically restrained the resident's lower extremities to provide personal care, which was against the facility's policy and resident rights. The incident was discovered during a review of the resident's progress notes by a registered nurse. The LPN involved documented the event, noting that the resident was yelling and swearing at staff and refused care. Despite knowing it was wrong, the CNAs complied with the LPN's instructions to restrain the resident. The resident's care refusals had previously been managed by leaving him alone and reapproaching later, and sometimes he accepted care after being informed of the consequences of refusal. Interviews with staff revealed that the resident was not usually physically aggressive and related better to some staff members. The facility had a protocol for managing care refusals, which included reapproaching the resident and using staff with whom he had a rapport. The personnel files of the involved staff showed that their certifications and training were current, and there were no prior concerns. However, the LPN was terminated following the incident, and the CNAs were required to undergo additional training.
Failure to Ensure Resident Safety and Supervision
Penalty
Summary
The provider failed to ensure the safety of a resident who was assisted out of the building by a registered nurse and subsequently left the facility grounds without staff knowledge. The resident was returned to the facility by an unknown individual, and upon return, was not appropriately assessed for potential harm, nor was his physician notified in a timely manner. The resident had a severe cognitive impairment with a BIMS score of 0 and diagnoses including Alzheimer's disease, anxiety disorder, and hemiplegia. Another resident's care plan was not followed, leading to her being left unattended in her wheelchair at the nurses' station. This resident was found on the floor by a CNA, who alerted the nurse. The resident was assessed and found to have no injuries. The resident had a BIMS score of 9, indicating severe cognitive impairment, and her care plan specified that she should not be left alone in her wheelchair due to her tendency to unbuckle her seat belt and slide or throw herself out of the wheelchair. The incidents highlight a failure in supervision and adherence to care plans for residents with severe cognitive impairments, resulting in potential risks to their safety. The staff involved did not follow established protocols for monitoring and supervising residents, leading to these deficiencies.
Failure to Timely Report Resident Elopement
Penalty
Summary
The provider failed to adhere to their policy regarding the timely reporting of neglect in an incident involving a resident's elopement. On the specified date, a registered nurse (RN) assisted a resident outside but was unable to monitor them. The facility's camera footage later showed that the resident was no longer in view, and they were found by a passerby approximately 125 yards away from the facility. The RN did not notify management of the elopement immediately, and the incident was only reported to the Minimum Data Set Nurse/Care Plan Coordinator/RN the following day. The delay in reporting the incident to the South Dakota Department of Health (SD DOH) was due to the RN's failure to notify the director of nursing or any management staff promptly. The facility's policy required immediate notification of such incidents to the appropriate authorities, but the initial Facility-Reported Incident (FRI) was submitted to the SD DOH beyond the required 24-hour timeframe. The director of nursing submitted the report after consulting with the Regional Nurse Consultant, which contributed to the delay.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rapid City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fountain Springs Healthcare | 1 mi | ★★★★★ | 11 | 0 |
| Avantara Mountain View | 1.9 mi | ★★★★★ | 10 | 0 |
| Avantara Saint Cloud | 2 mi | ★★★★★ | 6 | 0 |
| Avantara Arrowhead | 3.4 mi | ★★★★★ | 20 | 0 |
| Good Samaritan Society - St Martin Village | 3.5 mi | ★★★★★ | 3 | 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.