Deficiencies (last 4 years)
Deficiencies (over 4 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% better than South Dakota average
South Dakota average: 3.3 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 17, 2025
Visit Reason
The inspection was conducted following a complaint related to a resident fall incident on 6/29/25 where the facility failed to provide adequate supervision and assistance during a transfer, resulting in a resident falling while being transferred by a certified nursing assistant (CNA).
Complaint Details
The complaint investigation found that a resident fell on 6/29/25 during transfer by CNA C who did not follow the care plan requiring two staff members and mechanical lift assistance. The fall was not reported timely, no neurological assessments were done immediately, and family notification was missing. The CNA was terminated, and corrective actions were implemented. The citation is considered past non-compliance.
Findings
The provider failed to ensure safe transfer procedures and timely reporting of the fall incident. The CNA did not follow the resident's care plan requiring two staff members and mechanical lift assistance, did not report the fall properly, and the resident was not assessed immediately after the fall. Corrective actions including staff education, competency checks, audits, and termination of the CNA involved were implemented and confirmed.
Deficiencies (1)
Failed to provide adequate supervision and assistance to prevent a resident fall during transfer.
Report Facts
Date of fall incident: Jun 29, 2025
Date of survey completion: Jul 17, 2025
Date of report: Mar 17, 2026
Number of residents sampled: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Involved in resident fall incident and terminated for failure to follow care plan and report fall |
| CNA B | Certified Nursing Assistant | Witnessed fall incident and reported to nurse |
| LPN E | Licensed Practical Nurse | Notified director of nursing about fall and instructed fall follow-up |
| DON D | Director of Nursing | Instructed fall follow-up and reviewed fall sensor footage |
| RN F | Registered Nurse | Assessed resident after fall and instructed CNA |
| Administrator A | Administrator | Reviewed footage, suspended and terminated CNA C, and led corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The inspection was conducted following a complaint or allegation regarding a resident acquiring a skin tear caused by a hazardous bed frame in the nursing home.
Complaint Details
The investigation was complaint-related due to a resident sustaining a skin tear from the bed frame. The resident and family declined emergency room evaluation. The CNA involved in the transfer was a traveler no longer employed at the facility.
Findings
The provider failed to ensure the bed frame was maintained and free of hazardous sharp areas, resulting in a resident sustaining a skin tear on her right lower outer ankle. The bed frame had exposed metal bars without protective caps, and corrective actions were delayed until after the injury occurred.
Deficiencies (1)
Failed to ensure a bed frame was maintained and free of hazardous sharp areas, causing a skin tear to a resident's right lower outer ankle.
Report Facts
Wound measurement: 6
Wound measurement: 3
Wound measurement: 0.5
Wound measurement: 6
Wound measurement: 2.2
Wound measurement: 0.1
Number of metal bars on bed frame: 7
Number of metal bars with protective caps: 3
Number of metal bars without protective caps: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Informed maintenance staff about bed frame hazard and communicated with surveyor |
| RN C | Registered Nurse | Confirmed sheepskin cover placed over bed frame |
| RN E | Registered Nurse | Evaluated resident's leg and bed, did not report bed hazard initially |
| LPN F | Licensed Practical Nurse | Provided wound care to resident |
| CNA D | Certified Nursing Assistant | Assisted with wound dressing removal |
| Director of Nursing B | Director of Nursing | Expected reporting of equipment problems and agreed bed should have been investigated |
| CNA I | Certified Nursing Assistant | Assisted resident during transfer when skin tear occurred; was a traveler no longer employed |
| Maintenance Staff H | Notified about bed frame hazard by Administrator A | |
| CNA G | Certified Nursing Assistant | Believed resident cut leg on bed frame bars |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to evaluate compliance with care planning requirements, side rail safety assessments, and other regulatory standards at Avantara Clark City nursing home.
Findings
The facility failed to update the 48-hour nutritional care plans for two sampled residents in a timely manner and did not complete quarterly side rail assessments for three residents. The dietary portion of comprehensive care plans was not updated as expected, and side rail assessments and physician orders were missing for some residents.
Deficiencies (2)
Failure to ensure 48-hour nutritional care plans for two residents were updated in their comprehensive care plans.
Failure to complete quarterly side rail assessments for three residents.
Report Facts
Weight loss: 100
Weight: 133.6
Weight: 127.8
Side rail audit date: May 30, 2023
Quarterly side rail evaluation dates: 2
Quarterly side rail evaluation dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager H | Dietary Manager | Interviewed regarding care plan updates and dietary portion of care plans. |
| Director of Nursing A | Director of Nursing | Interviewed regarding care plans and side rail assessments. |
| Maintenance Director E | Maintenance Director | Interviewed regarding side rail assessments and audits. |
| Minimum Data Set Coordinator F | Minimum Data Set Coordinator | Interviewed regarding side rail assessments. |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 17, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control protocols, specifically focusing on hand hygiene practices among staff during resident care.
Findings
The provider failed to ensure proper hand hygiene was performed by three of five observed staff members while providing care to three sampled residents. Observations and interviews revealed multiple instances where staff did not perform hand hygiene between glove changes or after contaminated tasks, contrary to facility policy.
Deficiencies (1)
Failure to ensure proper hand hygiene by staff during resident care, including not performing hand hygiene after glove removal and before putting on new gloves.
Report Facts
Residents observed: 5
Staff observed: 5
Residents affected: 3
Glove changes without hand hygiene: 3
Milliliters of water flushed: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Observed failing to perform hand hygiene after glove removal during personal care. |
| RN C | Registered Nurse | Observed failing to perform hand hygiene after glove removal during wound care. |
| LPN D | Licensed Practical Nurse | Observed failing to perform hand hygiene between glove changes during wound care and medication administration. |
| DON B | Director of Nursing | Interviewed regarding expectations for staff hand hygiene and wound care procedures. |
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