Inspection Reports for Avantara Huron
1345 Michigan Ave. SW, Huron, SD 57350, Huron, SD
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% worse than South Dakota average
South Dakota average: 3.3 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 14, 2024
Visit Reason
The inspection was conducted following facility-reported incidents involving neglect of residents, specifically failure to provide nighttime care for resident 425 and improper transfer assistance for resident 46, which resulted in a fall.
Complaint Details
The complaint investigation confirmed neglect occurred on 8/4/24 for resident 425 and again on 10/24/24 for resident 46. Both incidents were substantiated, and corrective actions including staff education and audits were implemented and confirmed.
Findings
The provider failed to protect residents from neglect by not providing proper nighttime care to resident 425 and not following the care plan for resident 46 during transfers, leading to a fall. Disciplinary actions and education were provided to involved staff, and corrective actions were implemented and confirmed.
Deficiencies (2)
CNA Z did not provide nighttime cares for resident 425, who was found in the same clothes from the previous day and incontinent of stool.
CNA G did not provide appropriate transfer assistance as directed in the care plan for resident 46, resulting in a fall.
Report Facts
BIMS score: 14
BIMS score: 99
BIMS score: 5
Date: Aug 4, 2024
Date: Oct 24, 2024
Audit duration: 4
Number of residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA Z | Certified Nursing Assistant | Failed to provide nighttime care to resident 425 |
| LPN AA | Licensed Practical Nurse | Charge nurse who failed to ensure staff followed care plan for resident 425 |
| CNA G | Certified Nursing Assistant | Misread care plan and did not provide appropriate transfer assistance to resident 46 |
| Administrator A | Administrator | Interviewed regarding neglect incident for resident 425 |
| Director of Nursing B | Director of Nursing | Provided education to staff and confirmed audits after resident 46's incident |
| Certified Medication Aide/CNA X | Certified Medication Aide/Certified Nursing Assistant | Interviewed about resident 46's transfer |
| Licensed Practical Nurse Q | Licensed Practical Nurse | Interviewed regarding resident 46's care plans and transfers |
Inspection Report
Routine
Deficiencies: 9
Date: Nov 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide bed-hold notices, incomplete baseline care plan summaries, inadequate pain management, improper dialysis monitoring, unsanitary kitchen conditions, inadequate infection prevention practices including improper handling of residents on contact precautions and poor cleaning of ice machines.
Deficiencies (9)
Failed to provide bed-hold notice to resident or representative for hospital transfers on two occasions.
Failed to ensure baseline care plan summaries were reviewed with residents or representatives for 14 of 29 residents.
Failed to timely review and revise care plan for one resident, including lack of interventions for behaviors and infection precautions.
Failed to provide adequate pain management for one resident due to lack of available prescribed medication.
Failed to ensure dialysis monitoring including vital signs were consistently obtained and documented post-dialysis for one resident.
Failed to maintain clean and sanitary kitchen conditions including improper food storage, undated and expired food items, and inadequate temperature monitoring.
Failed to maintain ice machine in clean and sanitary condition; pink slime present and rusted parts observed.
Failed to place residents with MRSA on appropriate contact precautions; residents remained on enhanced barrier precautions instead.
Failed to follow infection control practices during medication administration for a resident on COVID-19 precautions; nasal spray applicator was not wiped after use.
Report Facts
Residents affected: 14
Residents affected: 29
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Temperature readings: 12
Temperature readings: 41
Temperature readings: 45
Temperature readings: 34
Temperature readings: 52
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Q | Licensed Practical Nurse | Failed to wipe nasal spray applicator after administration to resident on COVID-19 precautions |
| LPN L | Licensed Practical Nurse | Reported no pain medication available for resident 375 despite active order |
| RN C | Clinical Care Coordinator Registered Nurse | Acknowledged failure to advance resident 424 from enhanced barrier precautions to contact precautions |
| DON B | Director of Nursing | Confirmed expectations for dialysis vital signs and infection control education gaps |
| Dietary Manager T | Dietary Manager | Reported kitchen temperature monitoring and food discard practices |
| Housekeeper K | Housekeeper | Reported cleaning practices for ice machine |
| Housekeeper Supervisor R | Housekeeper Supervisor | Confirmed rust and slime on ice machine and cleaning responsibilities |
| Maintenance Director I | Maintenance Director | Confirmed pink slime on ice machine and cleaning procedures |
| RN BB | Registered Nurse Infection Preventionist | Provided infection control education details |
| Staff Development Coordinator D | Staff Development Coordinator | Reported education on infection control and nasal spray administration |
| Certified Medication Aide U | Certified Medication Aide | Reported ice machine usage frequency |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 18, 2024
Visit Reason
The inspection was conducted to evaluate the cleanliness and maintenance of kitchen equipment and facilities, including the range hood vents, ice machine, and ceiling tiles, to ensure compliance with professional food safety standards.
Findings
The provider failed to maintain the range hood vents, ice machine, and ceiling tiles in a clean condition. Observations revealed greasy film and lint on the range hood vents, hard water scale on the ice machine, and water stains on ceiling tiles. Interviews confirmed inconsistent cleaning schedules and unclear responsibility for maintenance tasks.
Deficiencies (3)
Range hood vents covered with greasy film and lint.
Ice machine sides and back had hard water scale buildup.
Ceiling tiles above refrigerator had dark water stains.
Report Facts
Cleaning tasks completed: 5
Survey completion date: Jun 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary aide C | Dietary Aide | Interviewed regarding range hood cleaning schedule and maintenance |
| Dietary manager A | Dietary Manager | Interviewed regarding range hood, ice machine, and ceiling tile maintenance and cleaning |
| Maintenance director B | Maintenance Director | Interviewed regarding maintenance responsibilities and cleaning schedules for kitchen equipment |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
The inspection was conducted as an annual survey of the Avantara Huron nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected were both reported as unknown.
Inspection Report
Deficiencies: 0
Date: May 2, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Avantara Huron nursing home, summarizing the findings from the survey completed on May 2, 2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 20, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify the family of a resident's change in condition.
Complaint Details
The complaint investigation found that the family had not been contacted on 2/2/23 or 2/3/23 when the resident became ill, despite policy requiring notification of change in condition.
Findings
The facility failed to notify the family of a resident's change in condition on 2/2/23 and 2/3/23 despite the resident becoming ill and subsequent physician calls. The resident was transferred to the emergency room on 2/4/23 and pronounced dead, with no prior family notification documented.
Deficiencies (1)
Failure to ensure the family was notified of a change in condition for one sampled resident.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 4, 2022
Visit Reason
The inspection was conducted following a complaint related to a resident fall resulting in injury due to improper use of assistive devices, specifically a wheelchair without foot pedals.
Complaint Details
The visit was complaint-related due to a fall incident involving resident 49 who was pushed in a wheelchair without foot pedals, causing her to fall and sustain a laceration and dental injury. The complaint was substantiated with findings of staff error and inadequate care plan updates.
Findings
The provider failed to ensure proper use of wheelchair assistive devices, leading to a resident falling and sustaining an injury. The investigation revealed that a certified nursing assistant pushed the resident's wheelchair without foot pedals, contributing to the fall. The facility initiated education and audits to prevent recurrence.
Deficiencies (1)
Failed to ensure proper use of assistive devices resulting in injury to a resident due to wheelchair being pushed without foot pedals.
Report Facts
Residents affected: 4
Fall event date: Jul 31, 2022
Pain scale: 9
Audit frequency: 4
Audit sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA L | Certified Nursing Assistant | Named in deficiency for pushing wheelchair without foot pedals |
| DON B | Director of Nursing | Completed provider report, provided education to CNA L, and planned audits |
| CNA K | Certified Nursing Assistant | Interviewed regarding resident's use of call lights and injury |
| Registered nurse/MDS coordinator F | Registered Nurse/MDS Coordinator | Interviewed about care plan revisions and fall circumstances |
| Corporate nurse consultant C | Corporate Nurse Consultant | Interviewed regarding audits and observations of resident care |
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