Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Fountain Springs Healthcare during CMS and state inspections, most recent first.
A resident who had recently fallen and been re-evaluated by PT was care-planned to be transferred with a stand aid lift, and this requirement was documented on the care sheet used by staff. Despite this, a CNA transferred the resident from a commode to a bed using only a gait belt and pivot transfer, after which the resident reported increased knee pain and received pain medication. Staff interviews confirmed that care sheets were the primary tool for communicating transfer status and that they were expected to follow them, but the facility could not provide a written policy on following care plans or using mechanical lifts, even though CNA duties required adherence to the plan of care and facility processes.
Respiratory equipment was not handled with proper infection control for multiple residents. A resident’s nebulizer mask was observed with visible spots and no cleaning documentation, another resident’s CPAP mask and tubing were found stored on the bed and not documented as cleaned for weeks, and several residents’ oxygen tubing and nebulizer equipment were left draped on beds, wheelchairs, floors, or other soiled surfaces instead of being stored cleanly. The DON and LPN confirmed the equipment in these conditions was contaminated or soiled.
Medication administration errors occurred when a CMA gave metoprolol before checking the resident's BP against the hold parameter, an RN split olanzapine without confirming it was appropriate and failed to document destruction of the unused half, and the RN incorrectly documented medications as administered after handing them to a CMA. An RN also failed to follow inhaler instructions for a resident using Trelegy Ellipta, as the resident swallowed water instead of rinsing and spitting it out.
Controlled medication accountability was not maintained for an E-Kit and for narcotic records for two residents. A secured E-Kit contained insulin pens, ABH topical dispensers, and an unlabeled Ativan bottle, but staff had no process to routinely account for all contents or monitor for removal. Narcotic reconciliation for one resident’s oxycodone showed missing documentation and unexplained count discrepancies, and another resident’s diphenoxylate-atropine record showed an altered remaining count with no documentation that unused tablets were destroyed or otherwise accounted for.
Failure to assess and obtain physician orders for self-administration of medications. Two residents were observed with meds left at bedside or nebulizer treatments in progress without staff present, while EMR review showed moderate cognitive impairment, no self-administration assessments, and no prescriber orders authorizing self-administration. The DON confirmed that leaving meds at bedside or leaving a resident alone during a nebulizer treatment would be considered self-administration.
A resident with intact cognition had conflicting documentation of advance directives and code status: the EMR banner and physician order indicated DNR, while the scanned advance directive showed the resident wanted CPR. The resident confirmed she wanted CPR, and staff interviews showed the LPN would follow the physician order if records conflicted; the DON acknowledged the physician should have been contacted and the EMR updated.
MDS Assessment Incorrectly Coded for Active Diagnosis: A resident with moderate cognitive impairment had bipolar disorder entered on the admission MDS, but the EMR contained no physician orders or documentation to support that diagnosis. The DON and MDS coordinator both stated they could not determine how the diagnosis got into the chart, and the MDS coordinator said it was an error on the admission MDS.
A resident admitted under a 100-day categorical PASRR approval was not rescreened when the stay extended beyond the authorized period. The EMR contained the initial hospital PASRR only, and the facility could not produce any later PASRR documentation. The DON said the SSD was responsible for PASRRs and agreed that additional screening should have been completed.
A resident admitted after a right tibia fracture repair, requiring non-weight bearing status and mechanical lift transfers, did not have a baseline care plan completed within 48 hours as required. Instead, staff relied on daily care sheets, and a transfer was performed using a slide board rather than the mechanical lift, causing the resident pain. The facility lacked a specific policy for baseline care plans, and key interventions were not added to the care plan until several days after admission.
A resident with dementia exited the facility unsupervised after her Wander Guard was removed and not replaced, with staff inaccurately documenting its presence. In a separate event, another resident's wheelchair was not properly secured during transport, resulting in injury when the chair tipped. Both incidents involved staff failing to follow safety protocols, placing residents at risk.
A resident reported to an LPN that a CNA had used inappropriate language, gestures, and a phone to take pictures and record her, and had stayed in her room despite being asked to leave. The incident was discussed among nursing staff and documented, but was not reported to the administrator, law enforcement, or state health authorities, and no investigation was initiated at the time. The allegations were only formally investigated and reported after the resident repeated them during a discharge follow-up call, at which point the CNA was terminated following validation of verbal abuse.
A resident with specific dietary needs choked on improperly prepared food and later died after staff failed to follow emergency protocols. The resident, who required a minced and moist diet, was served breaded cod that was not prepared correctly. Staff were confused about emergency procedures, delaying necessary interventions, and CPR was performed despite the resident's DNR status.
A CNA did not follow the manufacturer's instructions and the resident's care plan when using a standing frame mechanical lift, leading to a fall. The safety buckle was released while the resident was in the lift, but no injuries were reported.
Failure to Follow Care-Plan Transfer Method Using Mechanical Lift
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transferred according to her care plan and care sheet, specifically regarding the use of a stand aid lift. After a fall on 1/11/26, the resident, who had previously transferred with one-person assist and used a walker, began experiencing significant leg pain and was evaluated in the emergency room. Following this event, physical therapy re-evaluated her on 1/13/26 and recommended use of a stand aid lift for safe transfers, and this transfer status was reflected on her care sheet, which staff were expected to follow. Despite these updated transfer instructions, on 1/14/26 a CNA transferred the resident from the commode to the bed using only a gait belt and a pivot transfer instead of the ordered stand aid lift. The CNA later admitted to not using the stand aid lift as indicated on the resident’s care sheet. After this transfer, the resident complained of increased pain in her left knee, and the CNA notified the nurse, who provided pain medication. The incident was subsequently reported by physical therapy staff to the administrator and DON after the resident described the transfer and associated pain. Interviews and record review showed that staff were expected to provide care based on information in the resident’s care sheet, which included transfer status and other care needs, and that these care sheets were updated daily by management. Staff, including CNAs and nursing staff, confirmed that changes in a resident’s condition were to be communicated so that care sheets could be updated, and that new admissions were verbally reviewed and then formally assessed by PT for safe transfer recommendations. The facility was unable to provide a written policy for following residents’ care plans, using mechanical lifts, or transferring residents, even though the CNA job description required care consistent with the plan of care and facility policies and processes.
Respiratory Equipment Not Cleaned or Stored Properly
Penalty
Summary
Proper infection control practices were not followed for respiratory equipment used by multiple residents. During observation, resident 21 had a nebulizer machine with an attached mask on the bedside table, and the inside of the mask had small white spots. Resident 21 stated staff had not been cleaning the mask after nebulizer treatments and she could not recall when it was last cleaned. Her EMR showed an order for bedtime nebulizer treatment, but there was no documentation for staff to clean or change her nebulizer mask. Resident 16 had a CPAP machine on the bedside table, and the CPAP mask was observed lying on the bed under her pillow and later draped over the bed frame between the mattress and headboard. She stated that for the first six weeks in the facility her CPAP mask and tubing were not cleaned by staff, and that she had asked multiple times for weekly cleaning. Her EMR included an order for CPAP cleaning weekly, but the DON verified the CPAP mask and tubing had not been documented as cleaned for three weeks in a row during August. Resident 67 had an oxygen concentrator beside the bed, and the nasal cannula was draped over the over-the-bed table with the prongs lying on a hairbrush with gray hairs. Resident 79 had an oxygen concentrator beside the bed with the nasal cannula draped over the bed, later over the wheelchair, and the nebulizer mask hanging on the bedside table handle with a dated piece of tape on the tubing. The nebulizer chamber was partially filled with clear liquid and the inside of the mask was hazy and rough. Resident 97 had a nasal cannula attached to a portable oxygen cylinder on the wheelchair and another nasal cannula draped over the oxygen concentrator with the prongs touching the floor. The DON and LPN stated nasal cannulas and nebulizer masks that touched beds, floors, wheelchairs, or other soiled surfaces were considered contaminated and needed replacement, and the LPN verified the resident 79 equipment was not properly stored and appeared soiled.
Medication Administration and Inhaler Use Errors
Penalty
Summary
Nursing staff and CMAs failed to follow medication administration requirements for multiple residents. One CMA administered metoprolol succinate to a resident with a physician order to hold the medication if systolic blood pressure was less than 110, but she gave the medication before checking the resident's blood pressure. After administration, the resident's blood pressure was 142/73, and the CMA stated she did not see the parameter information below the medication order. An RN preparing another resident's medications split a 5.0 mg olanzapine tablet to create a 2.5 mg dose without first confirming with a pharmacist or the medical provider that splitting the tablet was appropriate. The RN discarded the unused half of the tablet into a destruction container but did not document the destruction. During the same medication pass, the RN handed the prepared Biofreeze and olanzapine to a CMA to administer to the resident, even though the RN had prepared the medications herself. The RN then initialed the MAR as if she had administered the medications, and the CMA stated she should not have administered medications she had not prepared herself. An RN also failed to properly instruct a resident on use of a Trelegy Ellipta inhaler. The resident self-administered one puff and then swallowed water after the inhaler use, while the inhaler instructions required rinsing the mouth with water and spitting the water out. The DON stated staff were expected to review the entire physician's order, including instructions, before administering medications, that the person who prepares a dose should administer it, and that medication destruction should be documented.
Controlled Medication Accountability and Narcotic Reconciliation Failures
Penalty
Summary
Pharmaceutical services were not provided in a way that ensured controlled medications in the Emergency Kit (E-Kit) were routinely accounted for. During observation of the medication room, a secured container in the medication refrigerator contained an E-Kit with a broken numbered plastic tag, a list of contents on the outside, and insulin pens inside. A second secured container in the same refrigerator held three ABH topical dispensers for residents 11 and 77 and an unlabeled unopened bottle of liquid Ativan in its original box. The medical records/CMA stated the Ativan bottle was part of the E-Kit but was too large to fit inside it, and the DON stated there was no process for regularly monitoring the tag number or accounting for the contents of that bottle. The DON also stated there was no process for accounting for the Ativan bottle and that diversion would be difficult to identify if it were removed or accessed. Narcotic administration and reconciliation were not accurately documented for resident 31. On one oxycodone reconciliation sheet, the record showed tablets remaining after administrations on several dates, but one line was missing the date, time, dose, and signature, and another line showed oxycodone removed for administration without a documented dose or signature. The resident’s MAR did not show oxycodone administered on that date, yet the nurse later stated she had given two oxycodone tablets and failed to document them on the MAR. The DON stated the accountability error had been brought to her attention by the pharmacy provider, but there was no documentation in the EMR, MAR, or reconciliation sheet explaining the discrepancy. A second oxycodone reconciliation sheet for resident 31 also contained an unexplained discrepancy at discharge, showing 24 tablets should have remained while 23 tablets were released to the resident or responsible party. The DON could not explain the difference. In addition, resident 98’s diphenoxylate-atropine reconciliation sheet showed two tablets removed for administration, but the quantity remaining was altered from 16 to 15 without explanation. The MAR showed one dose was administered, one was refused, one was held due to illness, and one was refused, and there was no documentation that the two tablets that were not administered were destroyed or otherwise accounted for. The facility policies reviewed stated that emergency kit contents were to be maintained in a designated locked area, medication administration was to be recorded immediately after giving the dose, unused controlled medication was to be documented on the accountability record, and controlled drugs were to be reconciled at final disposition.
Failure to Assess and Order Self-Administration of Medications
Penalty
Summary
The provider failed to ensure two sampled residents were assessed for the ability to safely self-administer medications and had physician orders to do so before medications were left for them to take on their own. One resident, who had a BIMS score of 12 and was documented as moderately cognitively impaired, was admitted in part because of non-compliance with taking medications. Observation showed a plastic cup with pills left on the over-bed table while no staff were present, and the resident stated staff had left her morning medications so she could take them slowly with breakfast because some upset her stomach. A second observation showed four pills still in the cup while the resident was waiting for breakfast, again with no staff present to ensure the medications were taken. The other resident had a BIMS score of 11 and was receiving nebulizer treatments three to four times per day. Observation showed an assembled nebulizer mask with clear liquid remaining in the chamber hanging on the bedside table handle, and the resident stated staff set up the treatment and sometimes left the room while he used it. An LPN confirmed she had administered the nebulizer after lunch and that at times she stayed in the room but other times left to the hallway, and she verified the clear liquid indicated the treatment had not been finished. Review of both residents' EMRs showed no physician orders for self-administration and no self-administration assessments. The DON stated the facility had no residents with self-administration assessments and physician orders in place, and verified that leaving medications at bedside or leaving the room during a nebulizer treatment would be considered self-administration.
Inaccurate Code Status Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of one resident’s advance directive and code status. Resident 5 had intact cognition with a BIMS score of 15, and her EMR banner displayed that she did not want CPR with a physician’s DNR order in place. However, her scanned advance directive, signed on [DATE], indicated that she did want CPR, creating a mismatch between the resident’s written wishes and the documented code status. During interview, Resident 5 stated that she had changed her advance directive on [DATE] and confirmed that she did want CPR. Staff interviews showed that an LPN relied on both the paper binder and EMR, but would follow the physician’s order if the paper form and order did not agree. The DON confirmed that the advance directive form indicated CPR was desired, that the physician should have been contacted for a new order to reflect the accurate code status, and that the EMR should have been updated.
MDS Assessment Incorrectly Coded for Active Diagnosis
Penalty
Summary
The provider failed to ensure that Resident 13’s MDS assessment was accurately coded for active diagnoses. Record review showed the resident was admitted on [DATE], had a BIMS score of 12 on 7/23/25 indicating moderate cognitive impairment, and had diagnoses dated 4/8/25 for bipolar disorder, anxiety disorder, and depression. The record also showed no physician orders related to bipolar disorder and no documentation supporting that diagnosis. During the survey, the DON stated the facility had searched through everything and could not determine how or why bipolar disorder was entered into the chart. The MDS coordinator stated she did not remember adding the diagnosis, did not know where it came from, could not find documentation to support it, and said it was an error on the admission MDS. The facility did not have an MDS policy available for review, and the RAI Manual states that active diagnoses must be supported by a physician-documented diagnosis and must be active during the 7-day look-back period.
Failure to Rescreen PASRR After Categorical 100-Day Approval
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one sampled resident who had been admitted under a categorical convalescent period approval for 100 days. The resident’s hospital PASRR dated 4/7/25 indicated she did not have a serious mental illness or developmental disability and approved her for a 100-day period. The record review showed she was admitted on [DATE], but there was no documentation in the EMR of any subsequent PASRR screening after the initial screen on 4/8/25, even though the expectation was that she would be rescreened within the approved 100-day period. During the survey, the facility could not provide documentation showing any PASRR screening completed after the initial approval. The DON stated that the SSD was responsible for completing residents’ PASRR screenings, but the SSD was not onsite during the survey. The DON also reported that she had contacted the SSD about resident 13’s PASRR screening, and the SSD agreed that additional PASRR screening should have been completed. The facility policy and the South Dakota Medicaid PASRR guidance both stated that short-term or categorical approvals that conclude require follow-up PASRR review before the approved period ends when the stay extends beyond the authorized period.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a recently admitted resident who had undergone a right tibia fracture repair and was non-weight bearing on her right leg. The resident required transfers using a full body mechanical lift, as indicated in her care plan and admission notes. However, the baseline care plan was not completed until several days after admission, and key interventions regarding her non-weight bearing status and transfer method were not added until seven days post-admission. On the evening following her admission, the resident reported to her daughter that a staff member was rough and rushed during a transfer to bed, which was performed using a slide board instead of the required mechanical lift. Although the resident was not injured, she experienced pain during the transfer and expressed a preference not to be cared for by the involved staff member. Staff interviews revealed that care sheets, which are updated daily, were used to guide care in the absence of a completed baseline care plan, but the official care plan outlining specific needs was not available to staff within the required timeframe. The facility did not have a policy specifically addressing baseline care plans and referenced federal requirements for developing and implementing such plans within 48 hours of admission. The DON confirmed that the baseline care plan was not completed as expected, and the responsible RN acknowledged that the care plan was not finalized at the time it was offered to the resident and her representative. This lapse resulted in staff relying on daily care sheets rather than a comprehensive, person-centered baseline care plan to guide immediate care needs.
Failure to Prevent Accident Hazards and Ensure Resident Supervision
Penalty
Summary
A resident with dementia and severely impaired cognition, who was at risk for wandering and elopement, was required to wear a Wander Guard device on both her wrist and wheelchair to prevent unauthorized exit from the facility. On one occasion, a staff member opened the entrance door for a visitor, and the resident was able to exit the facility undetected. The root cause was that an overnight shift nurse had removed the resident's Wander Guard prior to a medical appointment and failed to document its removal or communicate this to the day shift nurse. Upon the resident's return, the Wander Guard was not replaced, yet nursing staff continued to document that the device was present and functioning, despite it not being worn. In a separate incident, another resident was being transported by a facility-operated bus when the transport driver failed to secure the resident's wheelchair with the required floor straps. During the trip, the wheelchair tipped, causing the resident to hit her arm and sustain a scrape. The transport driver acknowledged not securing the wheelchair and only did so after the incident occurred. The driver had previously completed competency training for loading wheelchair passengers. Both incidents involved failures by staff to follow established safety protocols, including proper use and documentation of safety devices and adherence to transport safety procedures. These lapses resulted in residents being placed at risk for harm or injury due to inadequate supervision and failure to eliminate accident hazards.
Failure to Promptly Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to promptly investigate and report allegations of abuse involving a resident. On 12/29/24, a resident reported to an LPN, who was not assigned to her care that day, that a CNA had stayed in her room despite being asked to leave, used inappropriate language and gestures, and used a phone to take pictures and record her. Another staff member, a CNA, was also informed by the resident that the CNA in question had been disrespectful during personal care. The assigned RN, after being notified, went to the resident with two other staff members to discuss concerns, but the resident stated she had no concerns at that time. The CNA who received the complaint wrote a statement about the incident. The RN and LPN contacted the assistant director of nursing (ADON) to report the incident. The RN reported that the resident was having behaviors toward staff, while the LPN mentioned the resident's concerns about a CNA but did not provide specific details. The ADON instructed them to document the interaction and to ensure the staff member in question did not provide care to the resident. The following day, the director of nursing (DON) reviewed the progress notes and asked the social services director to speak with the resident, but no further information was obtained. Despite these actions, the incident was not reported to the administrator, law enforcement, or the state health department, and no formal investigation was initiated at that time. It was not until a discharge follow-up call several weeks later that the resident repeated the allegations, prompting the administrator to initiate an investigation and report the incident to the appropriate authorities. The subsequent investigation validated the allegation of verbal abuse, and the CNA involved was terminated. The delay in investigation and reporting constituted a failure to ensure that allegations of abuse were promptly addressed as required.
Failure to Follow Diet Order and Emergency Protocols Leads to Resident's Death
Penalty
Summary
The provider failed to ensure a physician-ordered diet was followed for a resident, leading to a choking incident during a meal service. The resident, who had a physician's diet order for regular texture with mildly-thick liquid consistency and minced and moist meats, was served breaded cod that was not prepared according to these specifications. The dietary manager confirmed that the cook did not process the fish correctly, which contributed to the resident's choking. During the incident, the resident was being fed by her visiting sister when she began to choke. Staff attempted to provide emergency medical intervention, including abdominal thrusts and CPR, but these efforts were not timely or appropriately executed. The resident, who had a DNR order, became unresponsive and passed away after emergency medical personnel arrived and took over the chest compressions. Interviews with staff revealed confusion and lack of clarity regarding the execution of emergency procedures. A CNA present during the incident did not perform abdominal thrusts due to uncertainty about her authority to do so, and a certified medication aide delayed performing abdominal thrusts until the resident was moved to another location. Additionally, the assistant director of nursing directed CPR to be performed despite the resident's DNR status, highlighting a breakdown in communication and protocol adherence.
Improper Use of Mechanical Lift Leads to Resident Fall
Penalty
Summary
On 4/29/24, a certified nursing assistant (CNA) failed to adhere to the manufacturer's instructions and the resident's care plan while using a standing frame mechanical lift. The CNA released the safety buckle while the resident was in the lift, resulting in the resident falling. Fortunately, the resident did not sustain any injuries from the fall.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Avantara North | 1 mi | ★★★★★ | 2 | 0 |
| Avantara Mountain View | 1.9 mi | ★★★★★ | 10 | 0 |
| Good Samaritan Society - St Martin Village | 2.5 mi | ★★★★★ | 3 | 0 |
| Avantara Saint Cloud | 2.5 mi | ★★★★★ | 6 | 0 |
| Avantara Arrowhead | 3.2 mi | ★★★★★ | 20 | 0 |
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