Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westhills Village Health Care Facility during CMS and state inspections, most recent first.
Advance directives were not maintained in the medical records for five sampled residents. Although admission paperwork and progress notes indicated that advance directive information had been reviewed for some residents, the actual documents or code status documentation were absent from the chart, and one resident’s baseline care plan did not address advance directives. The IDON stated the facility relied on baseline care plans to document residents’ wishes, but several were unavailable or stored offsite, leaving staff unable to confirm code status from the record.
Failure to follow a resident’s care plan for arm support was identified for a resident with hemiplegia and dementia. Staff observed the resident seated in a wheelchair without the required pillow under her left arm, despite a posted sign and care plan direction to support the arm with a pillow when up in the wheelchair. The CNA acknowledged forgetting to place the pillow, and leadership stated CNAs were expected to follow the care plan.
Staff failed to follow infection control practices for a resident’s urinary catheter supplies and for hand hygiene during assisted dining. Catheter cleaning supplies were observed stored in an unlabeled container on a shared bathroom floor with an uncapped urine collection bag, and two CNAs assisted two residents with eating without washing or sanitizing their hands between resident contacts or before feeding.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A cook in an LTC facility failed to change gloves and perform hand hygiene while handling food and utensils during meal services, leading to potential cross-contamination. Additionally, the cook used a rag from a sanitizer solution instead of individual alcohol pads to clean the temperature probe between food items, contrary to facility policy.
A CNA in a long-term care facility was reported for providing undignified care to five residents, including forcing a stroke-affected resident to walk despite unsteadiness, embarrassing another during an outing, and displaying aggressive and unprofessional behavior. The facility's administrator was initially unaware of these issues, and the CNA was removed from the schedule pending investigation.
The facility failed to maintain infection control practices during wound care, nasal cannula care, and personal care. An LPN used the same gloves throughout a dressing change and did not clean equipment, while nasal cannulas were improperly stored. A CNA did not follow hand hygiene protocols during personal care, using the same gloves for multiple tasks and failing to wash hands after handling soiled items.
The facility failed to ensure call lights were accessible for two residents, leading to deficiencies in accommodating their needs. One resident, affected by a stroke, often found her call light placed on her non-functional side, while another resident's call light was on the floor, out of reach. Interviews with CNAs revealed inconsistencies in call light placement, and the facility lacked a policy on call light accessibility.
The facility failed to follow physician's orders for two residents. A resident with a knee procedure was not assisted according to weight-bearing restrictions, as the CNA did not use a gait belt or provide verbal cues. Another resident's wound care was improperly conducted by an LPN, who did not apply prescribed Santyl cream and used unprescribed gentamycin ointment, while also failing to maintain infection control practices. These deficiencies were acknowledged by the DON.
Two residents were not screened for a history of trauma upon admission to the facility. One resident had significant past traumatic events and exhibited behavioral changes, while the other had severe cognitive impairment and mild depression. The facility lacked a formal trauma assessment tool and policy, leading to a deficiency in trauma-informed care.
Advance directives missing from resident records
Penalty
Summary
The provider failed to ensure that current advance directives were present in the medical records for five sampled residents. Review of the records for residents 7, 13, 26, 27, and 60 showed no advance directive paperwork or documentation of their wishes regarding code status in the medical record. For resident 26 and resident 27, progress notes by the ED stated that admission paperwork had been completed with advance directive information, but the actual advance directive documents were not found in the records. Resident 60 had admission paperwork and a baseline care plan in the record, but that paperwork did not include his advance directive. During interview, the IDON stated that the facility’s process was to identify residents’ advance directive wishes on the baseline care plan and keep that care plan in each resident’s medical record for staff reference. She acknowledged that resident 60’s baseline care plan did not address advance directives and that several residents’ baseline care plans were not available because they could not be found in the record or had been removed and stored offsite during record thinning. She also acknowledged that without this documentation in the medical record, staff could not confirm the residents’ code status and honor those wishes. The facility’s Advance Directives policy stated that the attending physician would be notified of any advance directives and that documentation would be maintained in the resident’s permanent record and reviewed routinely or as needed.
Failure to Follow Care Plan for Arm Support
Penalty
Summary
Provide appropriate treatment and care according to orders, resident preferences, and goals was not ensured for a resident with hemiplegia following a cerebral infarction and dementia. The resident’s care plan directed staff to support her left arm with a pillow when she was sitting in her wheelchair, and a sign in her room also instructed staff to place a pillow under her left arm when she was up in the wheelchair due to her stroke. During observation, the resident was seated in her wheelchair without a pillow under her left arm, with her left hand resting in her lap or her left arm positioned between her leg and the wheelchair armrest. The resident stated she was unsure when staff had last placed a pillow under her left arm while she was seated in the wheelchair. The CNA interviewed about the care stated she was aware of the sign but acknowledged she had forgotten to place the pillow under the resident’s arm. The therapy department had completed a Restorative Nursing Referral and Treatment Record, and the MDS coordinator stated she received it and implemented restorative therapy, then added the restorative task to the resident’s care plan for CNAs to implement. Facility leadership stated the pillow task was not added to the MAR to prompt CNA documentation, and both the ED and DON expected CNAs to follow the care plan. The provider’s care plan policy stated each resident’s comprehensive care plan is designed to assist in prevention of decline or maintenance of current functional status.
Infection Control Lapses With Catheter Storage and Hand Hygiene
Penalty
Summary
Staff failed to follow infection prevention practices for urinary catheter care for a resident who had been admitted to the facility and later had a urinary catheter placed after a bladder scan showed urinary retention. During observation, the resident’s catheter supplies were found in an unlabeled pink plastic container on the floor under the sink in a bathroom shared with a roommate. The container held distilled vinegar, an empty 60 cc syringe, and an unlabeled urinary catheter urine collection bag containing colorless liquid, and the bag’s tubing opening was uncovered. The resident’s electronic medical record showed the catheter had been placed after the bladder scan and that the resident was later admitted to the hospital for conditions unrelated to the catheter. On a later observation, the same pink plastic container with the catheter supplies was still on the bathroom floor. A CNA explained that catheter bags were to be changed between day and night use, cleaned with alcohol wipes, emptied, flushed with water, filled with vinegar using a 60 cc syringe, capped, and stored in the resident’s bathroom cabinet. RN C agreed the supplies were not stored correctly and acknowledged that the bag should have had a cap and the container should have been in the cabinet. Staff also failed to perform hand hygiene while assisting residents with eating. One CNA assisted two residents with bites of food and handled their utensils repeatedly without washing hands before or after touching the utensils. Another CNA fed the same two residents and did not wash or sanitize hands before assisting them. The executive director and interim DON/infection preventionist stated staff were expected to perform hand hygiene between assisting different residents, including during feeding, and to follow the facility’s catheter bag cleaning and storage policy.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or omissions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Improper Glove Use and Temperature Probe Cleaning in Meal Services
Penalty
Summary
The provider failed to ensure proper glove use and temperature probe cleaning during meal services. During an observation, a cook was seen wearing the same gloves while handling various food items and utensils, including waffles, hot dogs, and serving plates, without changing gloves or performing hand hygiene. This improper glove use was observed during two meal services, indicating a lack of adherence to proper food handling protocols. Additionally, the cook was observed using a rag from a sanitizer solution to clean the temperature probe between checking different food items, contrary to the facility's policy, which required the use of individual alcohol pads for cleaning. The Food Services Manager confirmed that the preferred method was not followed, increasing the risk of cross-contamination. The facility's hand hygiene policy did not specify expectations for glove use, and the food temping policy required the use of alcohol pads, which was not adhered to by the cook.
Inappropriate and Undignified Care by CNA
Penalty
Summary
The report details a deficiency involving inappropriate and undignified care provided by a certified nursing assistant (CNA) to five residents in a long-term care facility. Resident 33, who had a stroke affecting her left side, reported being forced to walk to the bathroom despite feeling unsteady, and described the CNA's tone as uncaring. Resident 35 recounted an embarrassing incident during a facility outing and felt harassed by the CNA, who later questioned her about their relationship. Resident 31's spouse observed a change in the CNA's attitude, describing it as harsh and unprofessional. Resident 19 reported rudeness and neglect, with the CNA refusing to assist her to the bathroom and making inappropriate comments about her needs. Resident 24 and his spouse described the CNA as aggressive and unprofessional, noting her behavior at the nurse's station. The facility's administrator was unaware of these issues until the survey, expressing a desire for residents to feel safe and respected. The CEO and administrator confirmed the incident involving Resident 35 and noted that the CNA's professionalism had been previously addressed. The CNA was removed from the schedule pending an internal investigation. The facility's Resident Rights policy emphasizes the importance of maintaining residents' quality of life, freedom from abuse, and respect for their individuality and self-determination.
Infection Control Deficiencies in Wound and Personal Care
Penalty
Summary
The provider failed to maintain proper infection control and prevention practices during wound care, nasal cannula care, and personal care. During a dressing change for a resident, an LPN placed dressing supplies on an unclean surface, used the same gloves throughout the procedure, and did not clean or disinfect scissors before returning them to the treatment cart. The LPN admitted to not following the facility's dressing change policy, which required using a clean field, changing gloves between wounds, and cleaning equipment. In another instance, nasal cannulas for two residents were found lying on the floor or wrapped around a portable oxygen tank, which were not clean storage areas. An RN confirmed that these practices were not in line with infection control standards. Additionally, a CNA was observed handling a nasal cannula that had fallen on the floor without cleaning it before giving it back to the resident. The CNA acknowledged the need to clean the cannulas before use. Furthermore, a CNA assisting a resident with personal care failed to use gloves when handling a soiled brief, did not perform hand hygiene after removing gloves, and used the same gloves for multiple tasks. The CNA did not follow the facility's hand hygiene policy, which required handwashing before and after resident contact and after handling soiled items. The RN and infection control nurse confirmed that the CNA did not adhere to standard precautions during the resident's care.
Inaccessible Call Lights for Residents
Penalty
Summary
The provider failed to ensure that in-room call lights were accessible for two residents, leading to deficiencies in accommodating their needs and preferences. Resident 33, who had a stroke affecting her left side, reported that her call light was often placed on her left side, making it inaccessible. On the morning of the observation, she did not have her call light and had to holler to get the attention of a CNA. Despite being cognitively intact, as indicated by her BIMS score, she did not have a pendant call light that could have been worn around her neck for easier access. Similarly, Resident 12 was observed calling out for help because her call light was on the floor and out of reach, preventing her from using it to request assistance to go to the bathroom. Interviews with CNAs revealed inconsistencies in the placement and accessibility of call lights. CNA K mentioned using gray push call lights clipped to residents' shirts or placed on trays, while CNA L ensured call lights were within arm's reach or on bedside tables. CNA M described placing call lights under sheets or clipped to beds, but all CNAs claimed they would notice if call lights were out of reach during frequent checks. The Director of Nursing expected staff to place call lights within reach and ensure residents knew how to use them, but there was no policy addressing call light accessibility. This lack of a formal policy contributed to the deficiency in ensuring residents' needs and preferences were reasonably accommodated.
Failure to Follow Physician's Orders for Weight-Bearing and Wound Care
Penalty
Summary
The provider failed to ensure physician's orders were followed for two residents, leading to deficiencies in care. For one resident, who had been admitted with a left total knee arthroplasty explantation and other medical conditions, the certified nurse aide (CNA) did not adhere to the prescribed weight-bearing restrictions. The resident, who was supposed to maintain toe touch weight bearing (TTWB) with contact guard assistance, was observed transferring without a gait belt and without receiving verbal cues or instructions from the CNA. The CNA was unaware of the resident's weight-bearing restrictions, which were clearly documented in the resident's electronic medical record and on a report sheet at the nurses' station. In another instance, a licensed practical nurse (LPN) did not follow the physician's orders for dressing changes on a resident with wounds on the lower extremities. The LPN failed to apply Santyl cream as ordered and used gentamycin ointment, which was not prescribed. Additionally, the LPN did not maintain proper infection control practices during the dressing change, such as not cleaning the bedside table before placing supplies and not performing hand hygiene between glove changes. These actions were contrary to the specific treatment orders documented for the resident's wound care. The director of nursing and other staff acknowledged the deficiencies in both cases. The lack of adherence to physician's orders and proper procedures for both residents highlights a failure in ensuring that staff were adequately informed and compliant with the care plans. This resulted in deviations from prescribed care, potentially impacting the residents' recovery and well-being.
Failure to Screen Residents for Trauma History
Penalty
Summary
The provider failed to ensure that two residents, identified as 15 and 34, were screened for a history of trauma upon their admission to the facility. Resident 15, who was admitted on 10/17/24, had a history of significant life events, including a flood and a wildfire that destroyed her home, as well as a developmentally disabled son. Despite these events, there was no assessment in her electronic medical record (EMR) that screened for any historical trauma. Interviews with the social services designee (SSD) revealed that there was no formal assessment tool available to screen for trauma, and the SSD was unaware of the resident's past traumatic experiences. Additionally, the resident exhibited behavioral changes, such as refusing care and preferring female staff, which were not linked to any trauma assessment. Similarly, resident 34, who had a severe cognitive impairment and mild depression, was not documented as having been asked about any traumatic events. The social services coordinator and consultant confirmed that there was no documentation in the admission assessment indicating that trauma had been screened for this resident. The facility lacked a Trauma Assessment policy, and there was no expectation or process for screening residents for trauma or cultural preferences, as confirmed by the administrator and the director of nursing/infection control nurse.
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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 Saint Cloud | 1.6 mi | ★★★★★ | 6 | 0 |
| Avantara Mountain View | 2.4 mi | ★★★★★ | 10 | 0 |
| Avantara Arrowhead | 2.6 mi | ★★★★★ | 20 | 0 |
| Clarkson Health Care | 3.1 mi | ★★★★★ | 1 | 0 |
| Avantara North | 3.6 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.