Inspection Reports for
Avantara Mountain View
916 Mountain View Rd, Rapid City, SD, 57702
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
Routine
Deficiencies: 7
Date: Dec 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to care planning, medication administration, dialysis care, infection control, medication labeling, and antibiotic stewardship at Avantara Mountain View nursing home.
Findings
The facility was found deficient in multiple areas including failure to update and follow care plans, improper accountability and documentation of controlled medications, medication administration errors, inadequate post-dialysis monitoring, improper labeling and storage of medications, failure to perform proper hand hygiene and whirlpool tub cleaning, and inappropriate antibiotic use without proper clinical assessment.
Deficiencies (7)
F 0657: The provider failed to ensure care plans for two residents were followed, updated, and revised promptly to reflect current status and care needs.
F 0658: The provider failed to adhere to professional standards for accountability of controlled medications and failed to accurately document medication self-administration and administration timing.
F 0698: The provider failed to ensure residents receiving dialysis were consistently monitored for abnormalities upon return from treatment.
F 0759: The provider failed to ensure medication error rates were below 5%, with errors including incorrect dosing, administration without physician orders, and failure to use measurement devices.
F 0761: The provider failed to ensure drugs and biologicals were properly labeled and stored, including unlabeled medications, outdated supplies, and insulin pens without pharmacy labels or proper dating.
F 0880: The provider failed to implement infection prevention and control practices including inadequate whirlpool tub cleaning and failure to perform proper hand hygiene during medication administration.
F 0881: The provider failed to ensure antibiotic use was monitored and that clinical criteria were met before antibiotic administration for a suspected urinary tract infection.
Report Facts
Medication error rate: 18.75
Medication administration record dates: 11
Dialysis vital sign documentation dates: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN I | Registered Nurse | Named in findings related to medication administration errors and insulin pen labeling. |
| DON D | Director of Nursing | Named in multiple interviews regarding care plan expectations, medication administration, and infection control. |
| CNA M | Certified Nursing Assistant | Named in findings related to whirlpool tub cleaning deficiencies. |
| LPN P | Licensed Practical Nurse | Named in findings related to controlled medication accountability and hand hygiene. |
| UMA K | Unlicensed Medication Aide | Named in findings related to medication administration and hand hygiene. |
| RN N | Registered Nurse | Named in findings related to medication administration, infection control, and medication labeling. |
| IP/LPN T | Infection Preventionist/Licensed Practical Nurse | Named in findings related to antibiotic stewardship and infection monitoring. |
Inspection Report
Deficiencies: 1
Date: Dec 12, 2024
Visit Reason
The inspection was conducted to investigate a facility-reported incident involving the failure to ensure functional wheelchair tie-down straps on a facility-operated bus, which potentially placed a resident at risk of harm during transport.
Findings
The provider failed to ensure one of two facility-operated buses had functional straps to safely secure a resident's wheelchair during transport. The facility implemented corrective actions including daily tie-down inspections, replacement of the non-functioning strap, staff education, and quality assurance audits, resulting in the non-compliance being considered past non-compliance.
Deficiencies (1)
F 0689: The facility failed to ensure one of two facility-operated buses had functional straps to safely secure a resident's wheelchair during transport, placing the resident at risk of harm. The tie-down system did not automatically tighten as designed.
Report Facts
Date of incident: Oct 19, 2024
Date of non-compliance confirmation: Dec 12, 2024
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 15, 2024
Visit Reason
The inspection was conducted following a complaint and reported incident involving inadequate pain management for a resident who self-inflicted a stab wound requiring surgical treatment.
Complaint Details
The investigation was triggered by a resident who self-inflicted a stab wound on 2024-05-04 due to inadequate pain management. The complaint was substantiated with findings of non-compliance in pain management processes.
Findings
The provider failed to ensure adequate pain management, including pain documentation, administration of pain medication without documentation, and accurate completion of pain assessments. Systemic changes and staff education were implemented following the incident.
Deficiencies (1)
F 0697: The provider failed to provide safe, appropriate pain management for a resident requiring such services, resulting in actual harm. Pain assessments and medication administration were inadequately documented, and standing orders were not consistently entered into the electronic medical record.
Report Facts
Pain level scores: 5
Pain level scores: 8
Pain level scores: 0
Pain level scores: 8
Pain level scores: 10
Tylenol dosage: 625
Brief Interview of Mental Status score: 14
PHQ-9 score: 0
Inspection Report
Routine
Deficiencies: 2
Date: Aug 23, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration and infection prevention and control practices at Avantara Mountain View nursing facility.
Findings
The facility failed to ensure proper medication administration procedures, including observation and documentation of medication intake by residents. Infection prevention and control practices were also deficient, including inadequate hand hygiene and glove use during resident care and medication administration.
Deficiencies (2)
F 0658: The facility failed to ensure medications were not left unattended without confirming resident intake and proper documentation by licensed nurses and unlicensed medication aides.
F 0880: The facility failed to implement infection prevention and control practices, including inadequate hand hygiene and glove use by staff during resident care and medication administration.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Named in medication administration and infection control deficiencies |
| LPN H | Licensed Practical Nurse | Named in medication administration deficiency |
| UMA I | Unlicensed Medication Aide | Named in medication administration deficiency |
| CNA D | Certified Nursing Assistant | Named in infection control deficiency |
| CNA F | Certified Nursing Assistant | Named in infection control deficiency |
| Director of Nursing B | Director of Nursing | Provided interview and oversight comments on deficiencies |
| Infection Control Nurse G | Infection Control Nurse | Provided interview on infection control expectations |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jun 29, 2022
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home care, including care planning, skin integrity, medication storage, infection prevention, and oxygen usage.
Findings
The provider failed to update care plans to reflect current resident needs, ensure routine skin evaluations and timely interventions for pressure ulcers, properly store insulin medications, and maintain infection prevention practices during wound care and oxygen equipment handling.
Deficiencies (5)
F 0657: Care plans were not updated to reflect current care needs for residents, including diet changes and oxygen use compliance.
F 0658: Routine skin evaluations were not completed as required to monitor skin integrity, leading to missed identification of infection and wound issues.
F 0686: Interventions to prevent pressure ulcer development were not implemented timely, resulting in actual harm to a resident with worsening wounds.
F 0761: Insulin medications and supplies were stored unlocked in resident rooms without proper evaluation or lock box use, contrary to policy.
F 0880: Infection prevention practices were not followed during wound care and oxygen equipment handling, including use of contaminated dressings and unclean scissors.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing C | Director of Nursing | Provided information on care plan updates, skin evaluations, insulin storage, and infection prevention |
| Licensed Practical Nurse G | Licensed Practical Nurse | Interviewed regarding oxygen usage and insulin administration |
| Dietary Manager E | Dietary Manager | Interviewed regarding resident 7's diet and care plan updates |
| Wound Care/Unit Manager D | Wound Care/Unit Manager | Performed wound care and provided information on wound care practices |
| Registered Nurse K | Registered Nurse | Observed performing wound care with noted infection prevention deficiencies |
| Licensed Practical Nurse H | Licensed Practical Nurse | Interviewed regarding insulin administration for resident 279 |
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