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 Saint Cloud during CMS and state inspections, most recent first.
A resident admitted for rehab after a femur fracture, on aspirin as a blood thinner and with mildly low Hgb/Hct, experienced multiple episodes of bile-colored emesis, low O2 saturation, weakness, pallor, and later hypotension and lethargy on the morning of a planned discharge. A CNA reported the vomiting to an RN, who assessed the resident, held medications, and later noted worsening weakness and pallor, but did not notify the physician or the resident’s first emergency contact despite these significant changes. When the resident’s granddaughter arrived to complete discharge, she questioned the resident’s condition, prompting a reassessment that showed low BP and increased lethargy; still, no provider or family notification occurred. The granddaughter, after consulting the assisted living facility, transported the resident by private vehicle, during which the resident became unresponsive, and the resident was then taken to the ER and hospitalized, where imaging revealed an acute and chronic subdural hematoma, a meningioma, a pulmonary embolism, and cholecystitis. Record review and interviews confirmed the lack of required notifications, in conflict with the RN job description and facility policies on change of condition and discharge/transfer.
A resident with a history of pneumonia, severe sepsis, upper respiratory infection, and vascular dementia developed cough and congestion and was evaluated by a PA-C, who entered orders for an antibiotic, medicated nebulizer treatments, and cough syrup into the HUCU messaging system and documented them in the EMR. The RN on duty, who had been told only to monitor the resident, did not log into the HUCU system, did not see or transcribe the new orders, and did not initiate the prescribed medications or communicate any new treatments to the next shift. The HUCU system did not generate alerts for new orders, and staff had to manually check for messages, which did not occur. The following day, after the resident returned from an outing with family and was found weak, non-responsive, and non-verbal, an LPN preparing to transfer the resident to the ER discovered the unprocessed orders in the HUCU system, confirming that the treatments had never been started.
Expired supplies and medications were found in storage rooms and on a med cart, including wound dressings, catheter kits, and other items past expiration. An RN left a med cart unlocked and unattended in the dining room while residents, staff, and visitors were nearby. In addition, two insulin products on the cart were not dated when opened, and an expired medication was also present.
Hand hygiene and safe feeding practices were not followed during meal assistance. A CNA and an LPN assisted multiple residents with eating without washing or sanitizing their hands between residents, and the CNA also handled a resident's wheelchair without hand hygiene. In addition, the CNA gathered food that had fallen onto a dining table and fed it back to a resident, even though the table was not a clean surface.
A resident with COPD and dementia had a prior hospital order for 3 L O2 via NC at bedtime, but staff did not clarify his oxygen needs after admission. The resident was observed with an oxygen concentrator and unopened tubing in his room, while staff were unsure of his oxygen instructions and there was no current physician order for oxygen. The DON and administrator confirmed the hand-off report indicated nighttime oxygen, but the order was not clarified.
A deficiency was cited for not ensuring that each resident was protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not update daily posted nurse staffing information to reflect actual staff numbers and hours worked during several overnight shifts. On multiple occasions, fewer LPNs and CNAs were present than indicated on the postings, and the postings were not corrected to show staff who left early or additional staff who arrived later. This occurred due to a lack of clear responsibility for updating the postings after key staff left their roles.
Two severely cognitively impaired residents experienced physical abuse by a CNA, including being forcibly grabbed and made to comply with care against their will. Staff witnessed and reported the incidents, and one resident was found with red marks on her wrists. Facility investigation and review of surveillance footage confirmed the abuse, resulting in the CNA's termination.
The facility failed to maintain cleanliness in the kitchen and dishroom, with lime build-up on cups, a non-functional plate warmer, and expired sanitizer test strips. Unsanitary food transport practices were observed, including uncovered fruit on room trays and improper handling of insulated covers, increasing cross-contamination risk.
The facility failed to maintain a clean environment, with strong urine odors and visible dirt in several areas, including resident rooms and utility rooms. A soiled utility room had overflowing containers, and the laundry room had maintenance issues. Interviews revealed a lack of cleaning schedules and insufficient staffing. A resident's urine-soaked chair was not properly cleaned, despite the facility's cleaning policy.
The facility failed to ensure resident privacy due to inadequate window coverings in several rooms, allowing visibility from outside at night. Additionally, a medication cart was left unlocked and a computer screen displaying a resident's EMR was left open during a medication pass, compromising privacy and security.
The facility failed to maintain a homelike environment, with multiple resident rooms exhibiting exposed sheetrock, missing paint, and other maintenance issues. The interim maintenance supervisor was unaware of the extent of these issues, and the facility's repair process was hindered by communication gaps and room availability constraints. The administrator acknowledged the slow progress in addressing these deficiencies.
The facility failed to provide proper diabetic fingernail care and dignified dressing for two residents. A resident with advanced dementia and diabetes had long, dirty fingernails, and there was no documentation of her nail care. Another resident with impaired cognition was found wearing socks labeled with other residents' names. Staff confirmed the issues, and the need for improved care and documentation was acknowledged.
The facility failed to follow physician's orders for compression garments for three residents, leading to inaccurate documentation in the TAR. One resident was without TED hose due to a lack of replacements, another lacked Redi-Wraps due to laundry issues, and a third had ill-fitting compression stockings. Staff were unaware of these issues, and the central supply room lacked the necessary sizes. The director of nursing acknowledged the failure to provide ordered treatments.
Failure to Notify Physician and Family of Resident’s Change in Condition Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician and the resident’s first emergency contact of a significant change in condition for one resident. On the morning in question, the resident experienced three to four episodes of bile-colored emesis between 6:00 a.m. and 7:00 a.m., appeared more tired, and had oxygen saturation readings of 88–89% on room air. A CNA reported the vomiting and dry heaving to the RN, who assessed the resident, obtained vital signs, held morning medications due to vomiting, and left the resident in bed with the head elevated, a vomit bag, call light, and a garbage can nearby. Later, around 8:30 a.m., the RN and CNA provided incontinence care after a bowel episode and observed that the resident appeared weak, pale, and unable to remain upright, after which the resident requested to return to bed. Despite these findings, the RN did not contact the physician or the resident’s first emergency contact at that time. The resident had been admitted for rehabilitation following a fall at an assisted living facility that resulted in a left femur fracture and was taking aspirin twice daily as a blood thinner. Prior lab work showed mildly low hemoglobin and hematocrit. It had been determined by the facility’s PA-C and the DON at the resident’s assisted living facility that the resident was doing well and was appropriate for readmission to assisted living later that morning. However, when the resident’s granddaughter arrived around 10:30 a.m. to complete discharge paperwork, she observed that the resident did not look well and questioned whether she should be evaluated before discharge. The RN then reassessed the resident, documented a blood pressure of 89/57, and noted increased lethargy after the resident was seated in a wheelchair. There is no documentation that the physician or first emergency contact was notified at this point, despite the documented change in condition. Following this reassessment, the granddaughter contacted the assisted living facility’s executive director, who advised that the resident be taken to urgent care or the ER before readmission. Around 11:00 a.m., the CNA assisted the granddaughter in transferring the resident into the granddaughter’s vehicle and observed that the resident’s condition worsened and she became unresponsive in the car. The granddaughter stated she was taking the resident to the ER, where the resident was evaluated and admitted to the hospital. Subsequent CT imaging revealed an acute and chronic subdural hematoma, a 12 mm meningioma, a pulmonary embolism, and cholecystitis. Record review confirmed there was no documentation that the resident’s physician or first emergency contact had been notified of the change in condition while the resident was still at the facility. Interviews with the RN, administrator, DON, and the physician confirmed that the RN did not notify the physician or the first emergency contact, despite facility policies and the RN job description requiring prompt notification of significant changes in condition and consultation with the medical provider and resident representative. Facility policies reviewed included a Notification of Change of Condition policy requiring prompt informing of the resident, consultation with the medical provider, and notification of the resident representative when there is a significant change in physical, mental, or psychosocial status, and a Discharge and Transfer policy requiring that if a resident’s needs change during discharge planning, the discharge plan may be updated and discharge should not proceed if the discharge location does not meet the resident’s needs, with contact to the medical provider in such cases. The RN acknowledged in interview that she did not call the physician or the first emergency contact when the resident’s condition changed and stated she had intended to update the family upon arrival and did not think to call the physician. The administrator and DON acknowledged that the physician and first emergency contact were not contacted when the resident’s condition changed and that the RN should have notified them promptly before discharge.
Failure to Transcribe and Initiate Physician Orders for Respiratory Treatment
Penalty
Summary
The deficiency involves a failure by nursing staff to ensure that physician orders for an antibiotic, medicated nebulizer treatment, and cough syrup were transcribed and initiated for a resident with respiratory symptoms. On 3/3/26, an RN reported that the resident was experiencing cough and congestion to a PA-C, who then evaluated the resident at the facility. The PA-C verbally told the RN and the DON that the resident should continue to be monitored but did not verbally communicate that new medications were being prescribed. The PA-C entered orders for an antibiotic, nebulizer treatment, and cough syrup into the HUCU messaging system and documented these orders in a progress note in the electronic medical record at 12:16 p.m. that day. The RN who had received the verbal report from the PA-C did not log into the HUCU messaging system to check for new orders for the resident after being told to monitor him. As a result, the orders entered by the PA-C on 3/3/26 were not transcribed into the nursing home's computerized medical record system and were not initiated. The RN also did not inform the night shift of any new medications for the resident and reported that the resident had no additional acute needs during her shift. The HUCU messaging system did not provide alerts when new orders or messages were sent, and the only way to identify new orders was for nurses to manually log in and check, which did not occur in this case. On 3/4/26, the resident left the facility with family for lunch and appeared to be at his baseline when observed by an LPN before departure. Upon returning around 1:00 p.m., the resident was later found by staff to be weak, non-responsive, sluggish, and non-verbal. The LPN caring for the resident attempted to contact his emergency contacts and, after speaking with his son, arranged for the resident to be sent to the ER for evaluation at approximately 2:15 p.m. While preparing for the transfer, the LPN logged into the HUCU messaging system to notify the primary care provider and discovered the PA-C’s orders from the previous day, which had not been transcribed or initiated. The resident was admitted to the hospital with diagnoses including sepsis related to pneumonia, elevated troponin, acute kidney injury, acute encephalopathy, and metabolic acidosis. Review of the resident’s records confirmed that no physician orders had been transcribed or initiated on 3/3/26 and that the facility’s policies required nurses to correctly and safely receive and transcribe physician orders, including those received electronically.
Expired and Unlabeled Medications and Unsecured Medication Cart
Penalty
Summary
Medications, biologicals, and supplies were not consistently labeled, stored, or discarded in accordance with policy and accepted practice. In the main storage room, surveyors observed multiple expired items, including a three-layer compression bandage system, Optifoam AG nonadhesive dressing, Opticell chitosan-based gelling fiber dressings, lemon-flavored glycerin swab sticks, catheter urine collection leg bags, and a Lidocaine 5% medicated patch on a shelf. In the small storage room, eight sterile catheter insertion kits were found expired, and one of the kits had been opened. The administrator and ADON acknowledged the expired items and stated that some of the supplies should not have been available for use. Medication storage and access were also not maintained securely. In the dining room, an RN left a medication cart unattended and unlocked while administering medications across the room, with residents, staff, and visitors passing by the cart. The RN acknowledged that the cart was not locked and that she was not directly observing it. The DON later confirmed that medication carts were expected to be locked when staff walked away from them. Facility policy stated that medication carts should remain closed and locked when out of sight and that access to medication supplies should be limited to authorized personnel. Labeling of medications with shortened expiration dates was also deficient. On a medication cart, Resident 61’s Lispro and Lantus insulin were not dated to show when they were opened, and the DON stated she could not tell whether they were expired because the opening dates were missing. Resident 73’s nystatin-triamcinolone was also found expired on the cart. The facility’s medication guidelines required date-opened stickers for medications with shortened end-of-use dating, and the storage policy required outdated medications to be removed from stock and disposed of according to procedure. The report also noted that no policy specific to outdated supplies was provided by the end of the survey.
Hand Hygiene and Safe Feeding Practices Not Followed During Meal Assistance
Penalty
Summary
The provider failed to ensure proper infection prevention and control during noon meal assistance in the main dining room. A CNA assisted three residents at one table and an LPN assisted two residents at another table without washing or sanitizing their hands between helping each resident eat. The CNA also handled residents' wheelchairs and meal plates without hand hygiene, including after moving a resident's wheelchair and after touching the wheelchair leg supports. The LPN similarly fed two residents repeatedly with her right hand without hand hygiene between residents. During the same meal service, the CNA also gathered food that had fallen off one resident's plate onto the dining room table by using two forks, then assisted that resident with eating the food from the table surface. The CNA acknowledged the table was not a clean surface and said it was not her normal practice to feed residents food that fell onto the table. The administrator, DON, and regional clinical consultant all stated staff were expected to wash or sanitize hands before and after resident care, between assisting each resident with eating, after moving or manipulating a wheelchair, and that food fallen onto the dining room table should be discarded rather than served to a resident.
Unclear Oxygen Orders Not Clarified After Admission
Penalty
Summary
The provider failed to ensure safe and appropriate respiratory care for a resident with COPD and dementia when staff did not clarify his oxygen needs after admission. The resident had a hospital order dated 7/31/25 to use 3 liters of oxygen via nasal cannula at bedtime, and his hospital discharge orders dated 1/14/26 did not discontinue that oxygen order. On admission to the facility, nursing documentation stated that he wore oxygen at 3 liters at night, and his baseline care plan included interventions to administer oxygen as ordered and assess respiratory status. During observation, the resident was found with an oxygen concentrator in his room, an unopened nasal cannula package on his bedside table, and he stated he thought he used oxygen but did not know how often. Staff interviews showed uncertainty about whether he needed oxygen and what his instructions were. The CNA did not know why the concentrator or tubing were present, and the LPN initially thought the hand-off report indicated oxygen at night but acknowledged there was no current physician order for oxygen and that the resident had no tubing connected to the concentrator. The LPN later obtained the prior hospital physician’s oxygen order, which stated oxygen at 3 liters per minute via nasal cannula every night, and stated the oxygen needs were not clarified during hand-off and that the resident may not have received oxygen at night since admission. The DON and administrator confirmed the hand-off report indicated oxygen at night, acknowledged there was no current physician order for oxygen, and stated staff should have clarified unclear details with the physician. The facility also had no policy regarding nurse hand-off reporting, and its oxygen administration policy required verification of a physician order specifying route, liter flow, and duration.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific actions or inactions leading to this deficiency are not detailed in the report, nor are particular events or resident conditions described. The deficiency is based on the facility's general failure to prevent abuse and neglect as required.
Failure to Accurately Update and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily posted nurse staffing information accurately reflected the actual number of nursing staff and the hours worked during three of four overnight shifts reviewed. According to the facility's own assessment, one to two licensed nurses and three to four CNAs were needed on the overnight shift to meet resident needs. However, interviews and time sheet reviews revealed that on several occasions, fewer staff were present than indicated on the posted staffing information. For example, on certain nights, only one LPN and two CNAs were present to care for 75 residents, despite postings indicating higher staffing levels. A review of posted staffing information for specific dates showed that the postings included the type and number of direct care staff and their hours worked. However, comparison with actual time sheets revealed discrepancies: on some nights, staff left their shifts early and did not return, and additional staff arrived only in the early morning hours to support the overnight and oncoming day staff. The posted information was not updated to reflect these changes, as required by facility policy, which states that actual hours must be updated if there are any changes to the schedule, number of staff, or hours worked after the start of each shift. The deficiency was further compounded by a lack of clear responsibility for updating the staffing postings. The staffing coordinator position had been vacant since April, and the unit manager who had assumed the responsibility left at the end of May. The administrator acknowledged that she had not taken over or delegated the task after the unit manager's departure, resulting in the failure to update the posted staffing information to accurately reflect actual staffing during the reviewed overnight shifts.
Failure to Protect Cognitively Impaired Residents from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect two cognitively impaired residents from physical abuse by a certified nursing assistant (CNA). In the first incident, a dementia champion reported that a CNA forcibly grabbed a resident's arms, forced her down into a chair, and made her bend her knees, causing the resident to cry. The resident had a history of Alzheimer's disease, dementia, and severe cognitive impairment, as indicated by a BIMS score of 0. A skin assessment following the incident showed no injuries, and staff interviews did not verify the abuse allegations. The facility was unable to retrieve camera footage related to this event. In a separate incident, the same CNA was observed by the activity director and another CNA physically forcing another severely cognitively impaired resident, who was yelling and refusing to go with him. The activity director intervened, instructing the CNA to leave the resident alone. The resident was found to have two small red marks on her wrists, which later resolved. The resident's care plan documented behaviors such as yelling, kicking, and rejection of care, and her BIMS score was 1, indicating severe cognitive impairment. Staff interviews and camera footage confirmed the physical abuse in this case. Both residents involved had significant cognitive deficits and were unable to advocate for themselves. The incidents were reported by staff who witnessed or heard the events, and the facility's investigation included staff interviews and review of available surveillance footage. The abuse was verified in the second incident, leading to the CNA's termination and reporting to the state board.
Deficiencies in Kitchen Cleanliness and Food Transport Practices
Penalty
Summary
The provider failed to maintain the kitchen and dishroom in a clean and functional manner, as observed during a tour and meal service. Plastic drinking cups used for the evening meal had a white-colored lime build-up and scratch-like marks, indicating improper cleaning. The dual plate warmer was not functioning on one side and was littered with food crumbs. A four-cup plastic measuring cup was stained brown and deemed uncleanable, yet still in use. The window ledge above the coffee makers was covered with a brown film, and the knife holder and cooking utensil drawer contained food crumbs and particles. Additionally, the Saf-T-Wrap dispenser holder had a build-up of an unknown substance. The dishroom had expired test strips for measuring sanitizer concentration, which were still being used despite the FSM being aware of their expiration. The air conditioner in the dishroom was covered with gray dust, blowing air over clean dishware and cooking equipment. The FSM was responsible for reviewing cleaning checklists, but the tasks were not completed adequately, leading to unsanitary conditions. Food transport practices were also deficient. Dietary aide O used bare hands to handle insulated dinner plate covers, increasing the risk of cross-contamination. Room trays with uncovered dishes of mixed fruit were left on the prep table for an extended period before being delivered to residents' rooms, contrary to the facility's policy that food should remain covered during transit. The FSM did not notice the uncovered fruit or the length of time it remained uncovered.
Inadequate Cleaning and Maintenance in Facility
Penalty
Summary
The facility failed to maintain a clean and odor-free environment, as evidenced by multiple observations of strong urine odors and visible dirt in various areas. A soiled utility room across from the secured unit entrance had overflowing containers of soiled linen and garbage, emitting a putrid odor of urine and feces. Despite the removal of these items, the room continued to smell strongly of urine, and the floor remained sticky. Additionally, two resident rooms in the 100 hallway were noted to have strong urine odors and visible brown smudges on the walls. The laundry room was found to have significant dust build-up, a leaking washing machine hose causing floor damage, and a handwashing sink with a dripping pipe and orange build-up. The clean utility room contained a basket of stained shoes and slippers placed next to clean linens. Interviews with housekeeping staff revealed a lack of cleaning schedules and insufficient staffing, leading to irregular cleaning practices and missed deep cleanings. The housekeeping supervisor admitted to falling behind on inspections and was unaware of specific maintenance issues in the laundry room. In resident 58's room, a brown lift chair was found to be urine-soaked and emitting a strong odor, despite being covered with a fabric. The resident expressed a preference for using the lift chair, but it had been turned to face the wall due to the soiling. The CNA acknowledged the chair was to be cleaned, but it remained in use without proper sanitation. The facility's cleaning policy emphasized the importance of immediate cleaning of soiled items, but this was not adhered to in this instance.
Privacy Breaches in Resident Rooms and Medication Handling
Penalty
Summary
The facility failed to ensure the privacy of residents in several rooms due to inadequate window coverings. Observations revealed that window shades in 12 out of 14 rooms in the 300 Hall and 5 out of 9 rooms in the 100 Hall did not provide sufficient privacy at night, allowing visibility from outside. The shades were effective during daylight but failed to protect residents' privacy at night, as they allowed unobstructed views from public areas such as sidewalks and parking lots. The facility's administrator was unaware of this issue until it was pointed out during the survey. Additionally, the facility did not secure electronic medical records and medication carts properly. During a medication pass in the main dining room, a registered nurse left a medication cart unlocked and a computer screen displaying a resident's electronic medical record open, making them accessible to other staff and potentially the public. The director of nursing expected staff to lock medication carts and secure computer screens, but these protocols were not followed, compromising the privacy and security of resident information.
Facility Fails to Maintain Homelike Environment Due to Maintenance Issues
Penalty
Summary
The facility failed to maintain a clean and homelike environment for residents, as evidenced by multiple observations of exposed sheetrock, missing paint, and other maintenance issues in various resident rooms across different hallways. Specific deficiencies included areas of exposed sheetrock near beds, worn recliner surfaces, black substance spills on walls, missing baseboard moldings, and cracked walls. These conditions were observed in numerous rooms, indicating a widespread issue with room maintenance and repair. Interviews with the interim maintenance supervisor revealed a lack of awareness regarding the extent of the maintenance issues. The supervisor, who was filling in temporarily, was not conducting regular inspections and was unaware of the need for immediate repairs in several rooms. The maintenance department relied on an electronic system, TELS, for repair requests, but there was a disconnect in communication and follow-up, as evidenced by the supervisor's lack of knowledge about the broken outlet cover and other deficiencies. The facility administrator acknowledged the issues and stated that contractors had been hired to address room repairs, but progress was slow due to room availability constraints. The administrator also admitted that touch-up painting had not been prioritized, contributing to the unhomelike environment. The housekeeping supervisor confirmed that staff did not have access to the TELS system, further complicating the reporting and resolution of maintenance issues. The facility's policy emphasized the importance of a homelike environment, but the observed conditions did not align with this standard.
Deficiencies in Resident Care and Dignity
Penalty
Summary
The provider failed to ensure proper diabetic fingernail care and dignified dressing for two residents. Resident 31, who was on hospice care for multiple co-morbidities including advanced dementia and diabetes, was observed with long, uneven fingernails caked with a dark brown substance, and an odor of feces was detected at her bedside. Despite being dependent on staff for all hygiene needs, there was no documentation of when and by whom her nail care was completed. The assistant director of nursing and a hospice RN confirmed the resident's fingernails were in poor condition, and the director of nursing acknowledged the need for improved performance and documentation of diabetic nail care. Resident 8, who had severely impaired cognition and rarely made her own decisions, was observed wearing socks labeled with other residents' names on two separate occasions. A certified nurse aide confirmed that staff chose the resident's clothes each day and that the socks worn were donated, despite the resident having her own socks. The August 2019 SD State Long-Term Care Ombudsman Program handbook emphasizes the importance of treating residents with consideration, respect, and dignity, which was not upheld in these instances.
Failure to Follow Physician's Orders for Compression Garments
Penalty
Summary
The provider failed to ensure that physician's orders for compression garments were followed for three residents. Resident 39, diagnosed with heart failure, was observed without TED hose despite a physician's order for their use to manage lower extremity edema. The Treatment Administration Record (TAR) inaccurately documented that the TED hose had been applied daily. Resident 8, with a diagnosis of edema, was observed without Redi-Wraps, although the TAR indicated they were applied as ordered. Similarly, Resident 65, with a history of chronic embolism and thrombosis, was not wearing the prescribed compression stockings, despite documentation suggesting otherwise. Interviews with staff revealed that Resident 39 was waiting for a replacement pair of TED hose, Resident 8's Redi-Wraps were not available due to laundry issues, and Resident 65's stockings were too tight, with the family expected to provide a new pair. The registered nurse (RN) responsible for documenting the treatments was unaware of the unavailability of these items and had relied on certified nurse aides (CNAs) to apply them. The central supply room had some compression garments in stock, but not the specific sizes needed for these residents. The Qualified Activity Director (QAD) and Central Supply staff were aware of the supply issues and had attempted to order the necessary items without success. The director of nursing acknowledged that the physician-ordered treatments were not provided and emphasized the need for a process to ensure adequate supplies. The RN Floor Nurse job description requires supervision of all treatments prescribed by physicians, highlighting a gap in compliance with this responsibility.
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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) |
|---|---|---|---|---|
| Avantara Mountain View | 1.1 mi | ★★★★★ | 10 | 0 |
| Westhills Village Health Care Facility | 1.6 mi | ★★★★★ | 3 | 0 |
| Avantara North | 2 mi | ★★★★★ | 2 | 0 |
| Avantara Arrowhead | 2.1 mi | ★★★★★ | 20 | 0 |
| Fountain Springs Healthcare | 2.5 mi | ★★★★★ | 11 | 0 |
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