Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
121% worse than South Dakota average
South Dakota average: 3.3 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 1
Dec 12, 2024
Visit Reason
The inspection was conducted to investigate a facility-reported incident involving the failure to ensure functional straps on a facility-operated bus to safely secure a resident's wheelchair during transport.
Findings
The provider failed to ensure one of two facility-operated buses had functional straps to safely secure a resident's wheelchair, potentially placing the resident at risk for harm. The facility implemented corrective actions including removal and replacement of the non-functioning strap, education of bus drivers, daily inspections, audits, and quality assurance processes.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure one of two facility-operated buses had functional straps to safely secure a resident's wheelchair during transport. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Date of incident: Oct 19, 2024
Date of corrective action: Oct 29, 2024
Date of confirmation: Dec 12, 2024
Inspection Report
Routine
Deficiencies: 8
Dec 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, medication administration, dialysis care, infection control, medication labeling and storage, 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 for residents, improper accountability and documentation of controlled medications, inaccurate medication administration including dosing errors and lack of physician orders, inadequate monitoring of residents post-dialysis, failure to perform proper hand hygiene during medication administration, improper cleaning of whirlpool tubs, and failure to ensure appropriate antibiotic use based on clinical criteria.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure care plans for two sampled residents were followed, updated, and revised promptly to reflect current status and care needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to adhere to professional standards and facility process for accountability of controlled medications by nursing staff signing verification sheets before physical inventory was completed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to accurately document assessment of appropriateness and safety of self-administration of medications for one resident and medication administration prior to documentation for another resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents receiving dialysis were monitored for abnormalities upon return from dialysis; post-dialysis vital signs were sometimes documented from previous days. | Level of Harm - Minimal harm or potential for actual harm |
| Medication administration errors including failure to use measurement device for topical gel dosing, administering incorrect dose of nasal spray, and applying topical powder without physician order. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure drugs and biologicals were labeled in accordance with professional principles; outdated medical supplies were stored; insulin pens lacked pharmacy labels and were used beyond expiration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program including inadequate whirlpool tub cleaning and failure to perform proper hand hygiene during medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement a program that monitors antibiotic use; antibiotic was prescribed and administered for a suspected UTI without appropriate clinical assessment or urinalysis. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 18.75
Number of residents affected: 2
Number of residents affected: 3
Number of residents affected: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN S | Licensed Practical Nurse | Signed controlled substances count sheet prematurely. |
| LPN P | Licensed Practical Nurse | Signed controlled substances count sheet prematurely. |
| RN I | Registered Nurse | Signed controlled substances count sheet prematurely; administered medications prior to documentation. |
| RN Q | Registered Nurse | Provided information on resident care plans and dialysis monitoring. |
| DON D | Director of Nursing | Provided expectations on medication administration, care plan updates, and dialysis monitoring. |
| UMA L | Unlicensed Medication Aide | Discussed medication measurement device use and medical supply management. |
| RN N | Registered Nurse | Observed medication administration and infection control practices. |
| CNA M | Certified Nursing Assistant | Observed whirlpool tub cleaning practices. |
| LPN F | Licensed Practical Nurse | Discussed documentation of nurse assessment and reporting of suspected UTI. |
| IP/LPN T | Infection Preventionist / Licensed Practical Nurse | Provided information on UTI assessment and antibiotic stewardship. |
| ADON E | Assistant Director of Nursing | Provided information on medication administration expectations and antibiotic stewardship. |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 15, 2024
Visit Reason
The inspection was conducted following a facility reported incident involving a resident who inflicted self-harm requiring surgical treatment. The investigation focused on the adequacy of pain management and related care processes.
Findings
The provider failed to ensure adequate pain management for one sampled resident who self-inflicted a stab wound requiring surgery. Deficiencies included lack of pain documentation, administering pain medication without documentation, and incomplete pain assessments. The facility implemented corrective actions including staff education and process changes.
Complaint Details
The visit was complaint-related, triggered by a facility reported incident involving a resident who self-inflicted a stab wound on 2024-05-04. The complaint was substantiated based on findings of inadequate pain management contributing to the incident.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide safe, appropriate pain management for a resident requiring such services. | Level of Harm - Actual harm |
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding pain management policies, standing orders, and documentation deficiencies. |
| ADM A | Administrator | Interviewed regarding the incident involving resident self-harm. |
| RN C | Registered Nurse | Interviewed about pain assessment and medication administration practices. |
| CNA D | Certified Nursing Assistant | Interviewed about responding to residents' pain reports. |
| CNA E | Certified Nursing Assistant | Interviewed about responding to residents' pain reports. |
Inspection Report
Routine
Deficiencies: 6
Aug 23, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, infection prevention and control practices, and medication administration procedures at Avantara Mountain View nursing facility.
Findings
The facility failed to ensure proper medication administration documentation and observation, infection prevention and control practices including hand hygiene and glove use, and appropriate cleaning of medical equipment such as CPAP tubing. Several staff members did not follow established policies, posing minimal to potential harm to residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Medications were left on a resident's over-the-bed table without ensuring the resident took them, and medication administration was documented without observation. | Level of Harm - Minimal harm or potential for actual harm |
| Unlicensed medication aide prepared and administered medications without proper documentation by licensed nurse. | Level of Harm - Minimal harm or potential for actual harm |
| Certified nursing assistant applied barrier cream with contaminated gloves without changing gloves or performing hand hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Licensed practical nurse failed to perform hand hygiene before handling resident's straw and administering medications. | Level of Harm - Minimal harm or potential for actual harm |
| Licensed practical nurse failed to perform hand hygiene and glove use properly during PEG tube dressing change. | Level of Harm - Minimal harm or potential for actual harm |
| CPAP tubing for a resident was not cleaned weekly as required, increasing risk of lung infection. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Named in medication administration and infection control deficiencies including leaving medications unattended, improper hand hygiene, and PEG tube dressing change |
| LPN H | Licensed Practical Nurse | Named in medication administration documentation deficiency |
| UMA I | Unlicensed Medication Aide | Named in medication administration deficiency for preparing and administering medications without proper documentation |
| CNA D | Certified Nursing Assistant | Named in infection control deficiency for improper glove use and hand hygiene during resident care |
| CNA F | Certified Nursing Assistant | Named in infection control deficiency for improper glove use and hand hygiene during resident care |
| Director of Nursing B | Director of Nursing | Provided interview clarifying expectations and confirming deficiencies |
| Infection Control Nurse G | Infection Control Nurse | Provided interview regarding infection control expectations |
Inspection Report
Routine
Deficiencies: 6
Jun 29, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to care planning, skin integrity, medication management, infection prevention, and oxygen use in a nursing facility.
Findings
The provider failed to update care plans to reflect current care needs for sampled residents, ensure routine skin evaluations and appropriate wound care, store insulin medications securely and evaluate residents for self-administration, and maintain infection prevention practices including proper oxygen cannula handling and cleaning of reusable humidifiers.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Actual harm: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to update care plans to reflect current care needs including diet and oxygen use for sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure routine skin evaluations and timely wound care for a resident with a left second toe amputation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident at risk. | Level of Harm - Actual harm |
| Failure to ensure insulin medications and supplies were stored securely and residents were properly evaluated for self-administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain infection prevention and control practices including proper handling of oxygen cannulas and cleaning of reusable humidifiers. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow infection prevention procedures during wound care, including use of clean dressings and cleaning of instruments. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 6
Skin evaluation dates: 5
Wound measurements: 7.5
Wound measurements: 3.5
Wound measurements: 2.5
Wound measurements: 0.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing C | Director of Nursing | Provided information on care plan updates, skin evaluations, insulin storage, oxygen use, and infection prevention. |
| Licensed Practical Nurse J | Licensed Practical Nurse | Interviewed regarding resident 7's diet and care plan. |
| Dietary Manager E | Dietary Manager | Interviewed regarding resident 7's diet and care plan updates. |
| Licensed Practical Nurse G | Licensed Practical Nurse | Interviewed regarding resident 49's oxygen use and resident 279's insulin administration. |
| Wound Care/Unit Manager D | Wound Care Nurse/Unit Manager | Performed wound care and provided information on wound care training and infection prevention. |
| Registered Nurse K | Registered Nurse | Assisted with wound care and was observed using contaminated scissors. |
| Licensed Practical Nurse H | Licensed Practical Nurse | Interviewed regarding resident 279's insulin self-administration. |
| Unlicensed Assistive Personnel I | Unlicensed Assistive Personnel | Interviewed regarding resident 279's insulin self-administration. |
| Administrator A | Administrator | Provided expectations regarding care plan updates. |
| Social Services Director F | Social Services Director | Interviewed regarding care plan updates. |
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