Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avantara Pierre during CMS and state inspections, most recent first.
A resident with dementia and a care plan for two-person full body mechanical lift transfers was pivot-transferred from his wheelchair to bed without a gait belt after staff found no sling under him. An LPN directed the transfer despite knowing the care plan, and the resident’s leg was caught on a bed frame with a missing cover plug, causing a large skin tear and puncture that required ER repair with staples and stitches.
RN/MDS coordinator review showed multiple MDS assessments were not signed by an RN within the required 14-day timeframe after the ARD for numerous residents, including quarterly, annual, PPS, significant change, and entry tracking assessments. The facility also failed to complete a discharge MDS for a resident who was transferred to the hospital and did not return; the RN/MDS coordinator confirmed the omission.
An LPN was observed administering insulin to a resident using a NovoLog pen that had a blank yellow expiration label. Review of insulin pens stored in the med cart found three open insulin pens for two residents, and none had expiration dates recorded on the labels. The DON stated the nurse who first opened each pen was expected to document the date opened and the shortened expiration date, and facility guidelines identified both NovoLog FlexPen and Lantus SoloStar as expiring 28 days after opening.
Staff failed to follow infection control practices during resident care, medication administration, and meal service. An LPN used an uncleaned pulse oximeter from a smock pocket, an RN and LPN did not consistently perform hand hygiene before and after glove use, a dietary aide touched ready-to-eat food with bare hands, and staff caring for a resident on EBP did not properly remove PPE or bag potentially contaminated laundry before leaving the room.
Resident's Clothing Marked With Name in Marker: A resident was observed wearing clothing with his first name written in black marker on his shirt and pant leg because he believed his laundry was not always returned. His donated clothing was not consistently labeled with individualized tags like another resident's clothing, and the SSD confirmed the resident had no local family support, relied on facility-donated clothes, and that the marker writing on his clothing was a privacy issue that compromised his self-esteem.
Failure to Assess and Secure Self-Administered Medications: A resident with COPD and moderately impaired cognition was observed receiving a nebulizer treatment without a self-administration assessment or physician order, and the RN left her alone while the treatment continued. Another resident with intact cognition self-administered a Symbicort inhaler and fluticasone nasal spray, but staff left both medications on her bedside table for hours and overnight despite no order to keep them at bedside and an order to return them to the med cart after use.
A facility failed to protect residents from verbal, emotional, and physical abuse by staff and a contracted CNA. One resident was called a derogatory name, another had a CNA place a hand inside her brief while checking for incontinence, and two residents reported rough transfer care and rude, demeaning comments about room odors. The affected residents included individuals with impaired cognition as well as residents with intact cognition and diagnoses such as cerebral palsy, heart failure, and multiple sclerosis.
An LPN failed to assess and document a resident’s headache pain before giving PRN oxycodone and also failed to document the medication administration on the MAR. The resident was alert and oriented, had WNL vital signs, and the LPN completed a negative stroke assessment, but did not obtain a pain score or record the PRN dose as required by the MAR and facility policy.
Failure to complete trauma-informed care assessments for two residents with PTSD. One resident had PTSD, MDD, and anxiety with severely impaired cognition, and the other had PTSD with intact cognition and reported combat-related PTSD. Neither EMR documented a trauma-informed assessment or an offer of behavioral health counseling, and the DON acknowledged both residents were not offered counseling services.
A resident with major depressive disorder, depression symptoms, and suicidal thoughts did not receive continued behavioral health services as reflected in the record. Psychiatry notes documented loneliness, grief, poor sleep, low interest, and suicidal thoughts without plan or intent, and therapy was referred, but there were no later psychiatry notes, no scheduled therapy follow-up, and the care plan lacked non-pharmacological interventions. Staff also did not have the psychiatry information in the EMR, and the SSD and ADON were unaware of key mental health findings and documentation gaps.
Controlled substance counts and documentation were not consistently completed or accurate, and one resident’s oxycodone supply was found missing while shift count forms and controlled drug records showed missing signatures, missing documentation, and mismatched administration times. In addition, an RN gave a resident only one 60 mg fexofenadine tablet when the order was for 180 mg daily because she did not review the full order before administration.
Call Light Not Within Resident’s Reach: A resident with Parkinson’s disease, dementia, unsteadiness, and a fall history did not have an accessible call light while seated in his wheelchair watching TV. The call light was taped to a positioning pole near the bed, and both the resident and staff confirmed he could only use it if he moved his wheelchair back to the bed.
A resident with multiple chronic conditions reported acute pain and lack of pain medication to a nurse consultant. The night shift RN did not notify the on-call physician for pain medication orders, citing abnormal labs, and only offered non-pharmacological interventions, which were refused. No documentation of the pain complaint or interventions was made, and the process for contacting the on-call physician was not clearly posted or included in orientation, resulting in a deficiency in pain management.
A resident with frequent loose stools due to lactulose for hepatic encephalopathy was not provided personal hygiene after an incontinent episode before being sent to the ER. The RN on duty, aware of the resident's condition, did not clean the resident prior to ambulance transport, resulting in the resident arriving at the hospital in a soiled state and feeling distressed by the situation.
A resident with hemiparesis, diabetes, and impaired mobility was admitted at high risk for pressure ulcers, but physician-ordered prevention interventions such as an air mattress and heel protection were not implemented or documented. The care plan did not include these measures, and the resident developed a new pressure ulcer before any prevention equipment was provided. Staff confirmed that required interventions were not in place prior to the ulcer's development.
Fifty residents who signed arbitration agreements at admission were not given the required 30-day period to rescind the agreement, as the document only allowed 10 days. A resident interviewed was unaware of the arbitration agreement details, and the administrator confirmed all affected residents received the same version. The facility's policy stated a 30-day rescission period, but the agreement provided to residents did not match this policy.
Three residents experienced cold and uncomfortable room temperatures, as confirmed by observations and temperature readings below the facility's required range. Residents reported having no control over their room temperatures and used extra blankets or walked the halls to stay warm. The facility's boiler system and leaking windows contributed to the issue, and only maintenance staff could adjust locked thermostats, which were not located in resident rooms.
Four residents did not have their care plans accurately updated or interventions implemented as required, including missing or improperly placed fall mats and call lights, lack of documented pressure ulcer prevention measures, failure to provide a required positioning alarm, and omission of physician-ordered lymphedema wraps from the care plan. These deficiencies were identified through observations, interviews, and record reviews.
Staff did not follow enhanced barrier precautions when providing direct care to a resident with a catheter, MDRO, and a pressure injury, as gloves were used but gowns were not worn. In the whirlpool tub room, CNAs failed to use the correct disinfectant and cleaning procedure as outlined by the manufacturer's instructions, and cleaning products were not properly labeled or dated. The laundry room had uncleanable surfaces due to damaged flooring and walls, improper airflow from a fan, and lift slings stored on the floor, with cleaning logs showing incomplete maintenance.
A resident was allowed to self-administer medications, including a nebulizer treatment and nasal spray, in their room without staff supervision or a physician's order, despite an evaluation indicating the resident was not able to self-administer medications. Staff left medications at the bedside, and the DON confirmed the absence of required authorization and assessment per facility policy.
A resident with a history of burns from smoking and mental health conditions was not assessed for smoking risks as required by facility policy. The care plan called for staff supervision and safety measures during smoking, but quarterly and readmission smoking risk assessments were missed. Staff interviews revealed confusion about who was responsible for completing these assessments, and the EMR system did not prompt for them, resulting in a failure to ensure adequate supervision and accident prevention.
Failure to Follow Care Plan During Resident Transfer
Penalty
Summary
The facility failed to ensure accident prevention interventions and transfer devices were used according to resident 29’s care plan. Resident 29 had a BIMS score of 9, indicating moderately impaired cognition, and diagnoses that included dementia with agitation. His care plan directed that he be transferred with a two-person full body mechanical lift for all transfers, but on the day of the incident he was moved from his wheelchair to his bed by a pivot transfer instead of the planned mechanical lift transfer. After resident 29’s shower, a contracted travel CNA initially used a full body mechanical lift to place him into a shower chair. When the resident refused a sit-to-stand lift transfer and stated he could stand, the CNA assisted him to stand using a grab bar and gait belt and placed him into his wheelchair. Later, when CNA R and a contracted travel CNA were preparing to transfer him from the wheelchair to the bed, there was no full body lift sling under him. CNA R asked an LPN how to proceed, and the LPN directed them to complete a two-person assisted pivot transfer. The transfer was completed without a gait belt, and resident 29 stated his legs were tangled during the transfer. After the transfer, staff observed bleeding from resident 29’s right lower leg. The LPN assessed the injury and found a large skin tear and puncture on the outside of the right lower leg. The resident was transported by ambulance to the emergency room, where the laceration was repaired with staples and stitches. The record also showed the bed frame had a missing cover plug at the location where the injury occurred, and a facility-wide bed plug sweep later identified multiple beds missing plugs. Interviews confirmed that staff knew the resident was supposed to be transferred with a full body mechanical lift, but the care plan was not followed during the transfer that resulted in the injury.
Late RN Signatures on MDS Assessments and Missing Discharge Assessment
Penalty
Summary
The facility failed to ensure that MDS assessments were signed by an RN within 14 days after the ARD for 19 of 19 sampled residents. Record review showed multiple quarterly, annual, PPS, significant change, and entry tracking MDS assessments with RN signature completion dates that occurred more than 14 days after the ARD. Examples included residents whose quarterly and annual assessments were signed late, as well as a resident whose entry tracking assessment was signed after the required timeframe. RN/MDS coordinator D confirmed she was responsible for reviewing each resident’s MDS for completion and signing the Z0500 section, and she acknowledged that the MDSs were not always signed within the 14-day requirement. The facility also failed to complete a discharge assessment for one resident who was transferred to the hospital and did not return. Record review showed the resident was transferred to the hospital, did not return to the facility, and was discharged, but no discharge return anticipated or return not anticipated MDS assessment was completed. During interview, RN/MDS coordinator D confirmed that no discharge MDS had been completed and stated, "I must have missed that."
Insulin Pens Stored Without Required Expiration Labels
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles because insulin pens with shortened expiration dates were left without expiration dates recorded on their yellow labels. During observation and interview, an LPN administering insulin to resident 10 was found using a NovoLog insulin pen with a blank yellow expiration label. The nurse who first used the pen was expected to document the shortened expiration date on the label, but that had not been done. Further observation of insulin pens stored in the medication cart showed two insulin pens for resident 10, one NovoLog FlexPen and one Lantus SoloStar, and one Lantus SoloStar pen for resident 27, and none of the three had an expiration date recorded on the yellow labels. The DON stated the labels were pre-placed with spaces for the date opened and the expiration date, and the nurse who opened the pen was expected to complete them. Facility guidelines identified both NovoLog FlexPen and Lantus SoloStar as expiring 28 days after opening, and the provider's injectable medication guidelines stated that opened multidose medications must have the date opened and triggered expiration date recorded.
Infection Control Failures During Resident Care, Medication Administration, and Food Handling
Penalty
Summary
The provider failed to ensure infection prevention and control practices were followed during resident care, medication administration, and food service. One LPN removed a pulse oximeter from a smock pocket and placed it on a resident’s finger without cleaning it first, then returned it to the pocket after use. During medication administration for another resident, an RN removed gloves from a smock pocket and put them on without performing hand hygiene first. The RN later acknowledged the gloves should not have been kept in the pocket and that hand hygiene should have been completed before donning gloves. During meal service, a dietary aide delivered a tray to a resident, removed the wrapper from a straw, and when part of the wrapper fell into the resident’s mashed potatoes and gravy, touched the food with an ungloved hand to remove it. The aide then placed the paper on the table, returned to the kitchen service window, performed hand hygiene with alcohol-based hand sanitizer, and continued delivering trays. The provider’s policy stated gloves must be worn when touching ready-to-eat food. Additional observations involved resident care for a resident on enhanced barrier precautions due to a PEG tube. An LPN and an RN did not consistently perform hand hygiene before and after glove use, and the RN handled items in the room and exited without removing PPE appropriately. The LPN wore a gown into the hallway, did not remove PPE before leaving the room, did not bag a potentially contaminated washcloth before exiting, and later placed the washcloth on the medication cart. The LPN also removed gloves and gown at different points, performed hand hygiene inconsistently, and documented medication and tube feeding administration after the sequence of events. The provider’s policies stated that hand hygiene was required before and after glove use, gowns were to be removed in the resident’s room, and soiled laundry was to be bagged before leaving the room.
Resident's Clothing Marked With Name in Marker
Penalty
Summary
The facility failed to protect the resident's right to dignity for one sampled resident who was wearing clothing with his first name written in black marker on the top of his left pant leg and on the left side of his shirt. During observation, the resident was sitting in his wheelchair watching television, and he stated that he wrote his name on his clothes because sometimes his laundry was not returned after washing. He also said his roommate's clothes had personalized labels affixed to the inside, while his own clothes were not labeled that way. He had other clothes that were not labeled with a black marker, but he did not wear them because he was concerned they would not be returned after laundering. The resident had no local family support and relied on donated clothing from the facility. The social services designee confirmed he had admitted to the facility after living in a local apartment and that no one had contacted his former landlord to retrieve his personal belongings. She also confirmed that most of his clothing was donated by the facility and should have been labeled before being provided to him. The laundry aide stated she used a heat-activated device to affix individualized labels to residents' clothing and knew not all of this resident's clothing had been labeled that way, while the social services designee agreed that the resident's name written in marker on his clothes was a privacy issue and compromised his self-esteem.
Failure to Assess and Properly Store Self-Administered Medications
Penalty
Summary
The facility failed to ensure residents were assessed for the ability to safely self-administer medications and had the required physician orders for self-administration and bedside storage. One resident with pneumonia and COPD, and a BIMS score of 9 indicating moderately impaired cognition, was observed in her room waiting for a scheduled DuoNeb nebulizer treatment. She stated she had not refused the treatment and believed the RN was late. The resident’s record showed an order for DuoNeb by nebulizer three times daily, but there was no self-administration assessment and no physician order authorizing her to self-administer the nebulizer treatment. During the observation, the resident was left alone while the nebulizer treatment was running. She fidgeted with the mouthpiece, repeatedly removed it from her mouth and replaced it, then fell asleep with the mouthpiece falling away from her mouth while the treatment continued. The RN walked past the room multiple times without checking on her. The RN later stated she knew the resident had not been assessed for self-administration and was not aware she should have remained with the resident during the treatment. The DON acknowledged the resident did not have a self-administration assessment or physician order to self-administer the nebulizer treatment. A second resident with intact cognition, COPD, and allergic rhinitis was observed with a Symbicort inhaler and fluticasone nasal spray on her bedside table. She stated she used them when she woke up and sometimes forgot to tell staff, leaving the medications on the bedside table for hours and at times overnight. Her record showed orders for both medications and a self-administration evaluation indicating she could self-administer them, but the evaluation also indicated there was no order to keep medications at bedside and that storage location was the medication cart. Staff stated they placed the medications at the bedside because the resident liked to sleep in, and the DON acknowledged the medications were left in the room for hours and overnight despite no physician order to store them there and an order stating they were to be returned to the medication cart after use.
Failure to Protect Residents from Abuse
Penalty
Summary
F600 was cited for failure to protect residents from verbal, mental, and physical abuse. One resident with recurrent major depressive disorder and moderately impaired cognition was verbally abused when a CNA called her a derogatory name and made a comment to her family member comparing them in a demeaning way. The resident’s record showed she had impaired cognition, and the incident was reported by her family member after it occurred. A second resident with cerebral palsy and a need for assistance with personal care was emotionally and physically abused by a contracted travel CNA who entered her room, commented that the room smelled, and then placed a hand inside the resident’s brief to check for incontinence by rubbing her buttocks and front area. The resident reported that the CNA’s actions occurred while checking whether her brief was soiled. The facility’s investigation confirmed that the CNA had been in the room with the resident that morning. Two additional residents were abused by another contracted travel CNA. One resident with heart failure and multiple sclerosis, and intact cognition, reported that the CNA was rough during a transfer and raised the bed too high, nearly causing her leg to fall out of the bed. Another resident with intact cognition reported that the same CNA entered her room and told her in a rude tone that her room smelled, which upset her. The facility’s investigations confirmed the allegations involving the CNA’s conduct toward both residents.
Failure to assess and document pain before PRN oxycodone administration
Penalty
Summary
An LPN failed to follow professional standards of nursing when she responded to a resident’s request to be seen for a cough and headache and the resident’s concern that she might have had a slight stroke because she felt unable to control her mouth secretions. The resident was alert, oriented, and able to answer questions, and her vital signs were within normal limits. The LPN completed a stroke assessment that was negative, but she did not assess the resident’s headache pain by asking about the location, type, duration, relieving factors, or intensity before preparing and administering a 5 mg PRN oxycodone tablet. The resident’s MAR indicated that staff were expected to document a numerical pain score before giving PRN oxycodone, but there was no pain level documented and no record of the oxycodone administration on the MAR for the dose given. During interview, the LPN acknowledged that she failed to assess, identify, or document the resident’s pain level before administering the PRN oxycodone and did not document the medication administration afterward. The DON stated that the pain assessment score was expected to be documented on the MAR before the PRN oxycodone was administered and that the administration was to be documented immediately after it was given.
Failure to Complete Trauma-Informed Care Assessments for Residents with PTSD
Penalty
Summary
The provider failed to complete trauma informed care assessments for two residents with PTSD diagnoses and did not document that behavioral health counseling was offered. One resident admitted with PTSD, major depressive disorder, and anxiety disorder had a BIMS score of 5, indicating severely impaired cognition, and her revised care plan did not include goals or interventions related to PTSD. Her EMR contained no documentation of a trauma informed care assessment to identify related needs or any offer of counseling. She was observed in bed with the television on and was nonverbal when questioned, and her emergency contact reported that staff kept him updated, he attended care meetings, and he had no concerns about her care. The second resident admitted with PTSD had a BIMS score of 15, indicating intact cognition, and his care plan identified altered mood and behaviors related to PTSD with interventions such as allowing him to choose activities, stopping to talk to him, and allowing positive interactions. His EMR also contained no documentation of a trauma informed care assessment or an offer of behavioral health counseling. He stated that he had PTSD from combat, that the facility did not offer much support for it, that he was not offered counseling services, and that he would like a referral for counseling. The SSD stated she had been unaware she was responsible for completing trauma informed care assessments until approximately three months earlier, and the DON acknowledged that both residents lacked the required assessments and were not offered counseling services.
Failure to Provide and Track Behavioral Health Services for Resident with Depression and Suicidal Thoughts
Penalty
Summary
The facility failed to ensure continued behavioral health services were provided for a resident with major depressive disorder, depression symptoms, and suicidal thoughts. The resident told surveyors she felt like giving up, had lost interest in activities, worried about finances, and had previously received counseling that she believed had helped, but she did not know why those counseling sessions stopped. Her record showed repeated PHQ-9 assessments with depression symptoms, including mild to moderately severe scores, and a psychiatry evaluation documented loneliness, grief, poor appetite and energy, daily anxiety, and suicidal thoughts without a plan or intent. The resident’s psychiatry notes showed that her antidepressant therapy was changed multiple times, a follow-up appointment was planned, and a referral was made for mental health therapy because the psychiatrist felt therapy would be beneficial. However, there were no psychiatry visit notes after the initial and follow-up visits reviewed, and the resident was not scheduled for the therapist referral or a psychiatry follow-up appointment. The care plan focused on antidepressant medication and monitoring for side effects and ongoing depression symptoms, but it did not identify any non-pharmacological interventions for depression. Staff interviews showed gaps in communication and documentation related to the resident’s mental health needs. The SSD stated she thought counseling had been offered, but there was no documentation that it was offered or declined, and she did not document her conversations with the resident. The ADON stated psychiatry notes were not in the EMR or reviewed before surveyor request, and she was unaware of the resident’s additional diagnoses, suicidal thoughts, PHQ-9 results showing moderately severe depression, or the therapy referral. The facility policy required assessment, individualized services, and consistent implementation of care approaches for residents with mental health issues.
Controlled Substance Accountability and Medication Dose Error
Penalty
Summary
The facility failed to maintain accurate controlled substance accountability and medication administration documentation for resident 24, who had an order for oxycodone 5 mg four times daily and a BIMS score of 15 indicating intact cognition. On 5/5/26, staff identified that one oxycodone 5 mg tablet was missing. The off-going and on-coming nurses searched the medication cart, hallway, and resident’s room and surrounding areas, but the tablet was not found. The resident’s MAR showed all scheduled doses were given, and the resident did not recall receiving an extra dose or being given two tablets. The report also noted that the controlled substance count on the East medication cart had been documented as accurate even though the count had not been completed with both nurses present. Review of the East medication cart controlled substance binder showed repeated instances where only one nurse signed the Shift Verification of Controlled Substances Count form, despite staff stating that both the off-going and on-coming nurses were supposed to count controlled medications at each shift change. LPN L acknowledged signing that the count was accurate before the count with the on-coming nurse had occurred. The review of shift verification sheets from January through June 2026 showed multiple missing signatures for both shift changes on several dates. The controlled drug receipt/record/disposition documentation for resident 24 also showed inconsistencies, including doses not accounted for, a missing form for 6/1/26 through 6/8/26, and multiple entries where the time the oxycodone was removed from the locked drawer did not match the time it was documented as administered in the MAR. The report further described that on 6/24/26, resident 24’s oxycodone supply from the pharmacy had run out, and RN W removed five tablets from the Nexsys to cover doses. DON B stated she expected nurses to document controlled medication removal and administration on the Controlled Drug Receipt/Record/Disposition Form, including when medication was removed from the Nexsys, but RN W did not know that requirement. DON B also acknowledged that the form for resident 24 was not found in the EMR for 6/1/26 through 6/8/26 and that there was no documentation on the controlled drug form for the 6/24/26 doses removed from the Nexsys even though the MAR showed the doses were administered. The report also identified a medication administration error for resident 66. RN G removed a 60 mg fexofenadine tablet from stock and administered one tablet along with other medications, but the physician’s order was for fexofenadine HCl 180 mg, one tablet daily. RN G stated she read only the administration instructions and not the full order. DON B stated the stock bottle label should have been compared to the MAR and the medication instructions for accuracy, and any discrepancy should have been reconciled before administration.
Call Light Not Within Resident’s Reach
Penalty
Summary
A resident with Parkinson’s disease, dementia, unsteadiness on his feet, and a history of falls did not have an accessible in-room call light while seated in his wheelchair. During observation, his call light was wrapped and secured with medical tape to the top of a positioning pole near the head of his bed, with the cord tucked behind the bedside table against the wall. The resident stated he had no access to the call light when he sat in his wheelchair watching television and would have to turn his wheelchair around and move it toward the bed to activate it for staff assistance. A later observation again showed the resident seated in his wheelchair watching television with no access to the call light taped to the positioning pole near his bed. The EMR showed care plan interventions directing staff to encourage him to use his call light and to keep it within his reach. A CNA acknowledged that securing the call light to the pole prevented access when he was in his wheelchair, and the DON agreed the resident could only reach it if he was in bed or able to move his wheelchair to the bed.
Failure to Notify Physician and Document Acute Pain Complaint
Penalty
Summary
A resident with multiple significant diagnoses, including cirrhosis of the liver, diabetes mellitus type II, cardiomyopathy, unspecified convulsions, difficulty with walking, and glaucoma, reported acute stomach pain to a senior regional nurse consultant. The resident also expressed concerns that two night nurses were not providing water or pain medication. At the time, the resident did not have any physician orders for pain medication, and his care plan included interventions for pain management, such as asking for medication and having pain levels reviewed every shift. On the night in question, the registered nurse (RN) on duty was aware of the resident's pain complaint but did not notify the on-call physician to obtain an order for pain medication. The RN cited concerns about the resident's abnormal lab values, specifically elevated liver enzymes and low platelets, as reasons for not administering acetaminophen or ibuprofen. Instead, the RN offered non-pharmacological interventions, such as repositioning, which the resident refused. The RN did not document the resident's pain complaint, the interventions offered, or the resident's refusals in the progress notes. The RN reported the situation to the oncoming nurse but did not take further action to address the resident's pain during her shift. Interviews with facility staff revealed that the process for contacting the on-call physician was not clearly posted or included in the nurse orientation checklist at the time of the incident. The director of nursing expected that nurses would notify the on-call physician if a resident without pain medication orders complained of pain, but this expectation was not met. The lack of timely physician notification and absence of documentation regarding the resident's pain and interventions led to the deficiency in providing safe and appropriate pain management.
Failure to Provide Personal Hygiene Prior to ER Transfer
Penalty
Summary
A resident who was cognitively intact and recently admitted to the facility experienced an episode of incontinence with loose stool prior to being transported to the emergency room (ER) for evaluation. The resident had a history of frequent loose stools related to lactulose use for hepatic encephalopathy and was on a strict fluid restriction. On the evening of the incident, after a total bed change was completed following an earlier incontinent episode, the resident again became incontinent of loose stool just before the arrival of the ambulance team. The registered nurse (RN) on duty was informed by the paramedic about the resident's condition. Despite this, the RN did not provide personal hygiene or clean the resident before transport, citing concern about making the paramedics wait. The resident was subsequently transported to the ER in a soiled state. Upon arrival at the hospital, staff there expressed their dissatisfaction with the resident's condition, and the resident reported feeling bad about the situation. The resident also stated that staff had time to change him before he left for the hospital and recalled hearing the paramedic inform the RN of his incontinence. The facility's policies on abuse, neglect, and resident dignity require that residents be provided necessary care to avoid harm or pain, including personal hygiene after incontinence. The failure to provide personal hygiene to the resident prior to ER transfer, despite awareness of his needs and the opportunity to address them, constituted neglect and a violation of the resident's right to dignity and proper care.
Failure to Implement Pressure Ulcer Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to identify and implement pressure ulcer prevention interventions for a resident who was at high risk for skin breakdown and dependent on staff for activities of daily living. Upon admission, the resident was assessed as high risk for developing pressure ulcers, with a Braden score dropping from 18 to 6 within four days, but there was no documentation that physician-ordered interventions such as the use of an air mattress, floating heels, or pressure redistributing cushions were initiated. The resident's care plan did not reflect these interventions, and there was no evidence that the pressure ulcer prevention and treatment orders were implemented upon admission. Observations revealed that the resident was using blue padded pressure-reducing boots and a compression stocking, but these were only provided after a pressure ulcer was identified on the right heel. The resident did not have an air mattress on the bed as ordered, and staff interviews confirmed that the required interventions were not in place prior to the development of the pressure ulcer. The wound care nurse and DON both acknowledged that the resident developed a new pressure ulcer after admission and that the prevention measures were not included in the care plan or implemented as required. The facility's policy required a plan of care for residents at risk for skin breakdown and immediate implementation of individualized prevention programs based on assessment. However, the lack of documentation and failure to follow physician orders and facility policy led to the development of a facility-acquired pressure ulcer in a resident with significant risk factors, including hemiparesis, diabetes, and impaired mobility.
Failure to Provide Required 30-Day Rescission Period for Arbitration Agreements
Penalty
Summary
The provider failed to ensure that 50 out of 55 residents who signed an Arbitration Agreement upon admission were explicitly granted the right to rescind the agreement within 30 calendar days, as required. Observation and interview with a cognitively intact resident revealed she was unaware of the specifics of the Voluntary Agreement for Arbitration she had signed and did not recall signing it. Review of her admission documents confirmed the inclusion of arbitration information, but the agreement itself only allowed a 10-day rescission period, contrary to regulatory requirements. Further review of the provider's undated Voluntary Agreement for Arbitration and policy showed a discrepancy: while the policy stated a 30-day rescission period, the actual agreement given to residents only allowed 10 days. The administrator confirmed that all residents admitted after the 2019 implementation had signed the same agreement and was unsure why the agreement did not reflect the 30-day period. The social services director, responsible for reviewing the agreement with residents, was unavailable for interview during the survey.
Failure to Maintain Adequate Room Temperatures for Residents
Penalty
Summary
The facility failed to maintain adequate room temperatures for three residents who reported their rooms were cold and uncomfortable. Observations confirmed that the rooms of these residents felt colder than other areas of the facility, and residents were observed using extra blankets, wearing additional clothing, and placing items along windows to block drafts. Residents reported having no control over their room temperatures and described ongoing discomfort, with one resident stating she had to stay in bed under blankets to keep warm, and another walking the halls to warm up. Temperature measurements taken in one resident's room showed readings below the facility's required range, with wall temperatures as low as 65.3°F, despite the facility's policy stating that resident room temperatures should be maintained between 71 and 81°F. The maintenance director acknowledged the difficulty in maintaining consistent temperatures due to the building's boiler system and leaking windows, and confirmed that thermostats were not present in resident rooms and were locked to prevent resident or staff adjustment. Only maintenance staff could adjust the thermostats, which were set between 70 and 72°F, and temperature checks were performed by averaging readings from a few rooms. Interviews with staff and review of facility policies confirmed that residents did not have the ability to control their own room temperatures and that complaints about cold rooms had been raised previously, including at a resident council meeting. The facility's homelike environment policy emphasized the importance of comfortable temperatures, but the observed conditions and resident reports demonstrated that the facility did not ensure a safe, comfortable, and homelike environment as required.
Failure to Implement and Update Resident Care Plans and Interventions
Penalty
Summary
The facility failed to ensure that care plans accurately reflected the current needs of four residents and that interventions listed in the care plans were implemented as directed. For one resident with a history of falls and severe cognitive impairment, observations revealed that the fall mat was not properly placed and the call light was not within reach, contrary to the care plan instructions. The resident's care plan specifically required the bed to be in a low position, a fall mat to be placed next to the bed, and the call light to be accessible, but these interventions were not consistently provided. Another resident, who was admitted with hemiparesis and later developed a pressure ulcer on the right heel, did not have appropriate pressure ulcer prevention interventions included in the care plan. Although physician orders and staff interviews indicated the need for an air mattress, pressure-reducing boots, and regular repositioning, these interventions were not documented in the care plan prior to the development of the pressure ulcer. The resident was only provided with pressure-reducing boots after the ulcer was identified, and there was no documentation of air mattress use or trial. A third resident, who required a positioning alarm (tabs alarm) as per physician orders and care plan, was repeatedly observed without the alarm in place while in bed or in a wheelchair. Staff interviews confirmed that the use of the tabs alarm was not consistently communicated or implemented. Additionally, a fourth resident with lymphedema received daily Ace wrap treatments from therapy staff as ordered by a physician, but this intervention was not included in the resident's care plan. Nursing staff were not trained on the use of the wraps, and the care plan did not address this aspect of care, despite expectations from facility leadership that all treatments should be reflected in the care plan.
Infection Control Deficiencies in Resident Care, Whirlpool Cleaning, and Laundry Room Maintenance
Penalty
Summary
Staff failed to follow appropriate infection control practices in several areas of the facility. Two certified nursing assistants (CNAs) did not use gowns while providing direct care, including personal hygiene and changing undergarments, to a resident who had a catheter, a multidrug-resistant organism (MDRO), and a pressure injury. The signage on the resident's door and the care plan both indicated that enhanced barrier precautions (EBP), including the use of gloves and gowns, were required during high-contact care activities. However, the CNAs only wore gloves and did not believe gowns were necessary unless they were emptying the catheter, which was inconsistent with facility policy and the infection preventionist's expectations. In the whirlpool (WP) tub room, two CNAs used different disinfectant products to clean the tub between resident uses, but neither followed the manufacturer's instructions. The spray bottles used for cleaning were not dated, and there was no indication of the required wet contact time for effective sanitization. The manufacturer's manual specified the use of a particular disinfectant, a long-handled brush for cleaning, and a specific procedure, none of which were followed. The director of nursing confirmed that the correct process was not used and that the required disinfectant was not available. The laundry room was also found to have multiple infection control deficiencies. There were uncleanable surfaces due to cracked or missing tiles and peeling paint, both in the main laundry area and the clean linen room. A wall-mounted fan was positioned to blow air from the soiled to the clean area, and mechanical lift slings were stored in a way that allowed them to touch the floor and accumulate dust. Cleaning logs for the laundry room were incomplete or missing for several days, and the infection preventionist confirmed that the areas were not being maintained or cleaned as expected.
Failure to Ensure Safe and Authorized Self-Administration of Medications
Penalty
Summary
A resident was observed self-administering medications, including a nebulizer treatment, Tums, and Fluticasone Propionate nasal spray, in his room without staff supervision. The resident stated he was able to independently manage his medications, and nurses left medications on his bedside table for him to take. Observations confirmed that no staff were present during the administration of the nebulizer treatment, and medications were accessible to the resident in his room. Review of the resident's electronic medical record revealed that a self-administration evaluation had been completed, which indicated the resident was not able to self-administer medications. Additionally, there was no physician order authorizing the resident to self-administer his medications, as required by the facility's policy. The DON confirmed both the lack of a physician order and the evaluation's findings. Staff interviews further indicated uncertainty about the resident's assessment status and the practice of leaving medications in resident rooms.
Failure to Complete Required Smoking Risk Assessments for Resident with Smoking-Related Injury History
Penalty
Summary
The facility failed to implement its smoking policy for a resident with a known history of smoking-related burns and mental health conditions, including paranoid schizophrenia. The resident's care plan required staff supervision during smoking, use of safety equipment such as a cigarette extender and protective apron, and storage of smoking materials in a locked area. Despite these interventions, the facility did not complete required smoking program evaluation assessments at admission, readmission, quarterly, and after hospitalization, as mandated by their policy. Specifically, there were no quarterly assessments between December 2023 and August 2024, and no assessment was completed upon the resident's return from hospitalization. Interviews with staff revealed confusion and inconsistency regarding responsibility for completing smoking risk assessments. Some staff believed floor nurses were responsible, while others stated that only the DON or a specific RN completed them. The EMR system did not automatically prompt for these assessments, contributing to missed evaluations. Staff were aware of the resident's need for supervision and the storage of smoking materials, but the lack of timely and consistent assessments represented a failure to ensure adequate supervision and accident prevention as required by facility policy.
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What surveyors actually found near you
We read the 14 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pierre
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avera Maryhouse Long Term Care | 0.1 mi | ★★★★★ | 14 | 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 August 2026) and official state health department websites.