Inspection Reports for Avantara Saint Cloud
302 St Cloud St, Rapid City, SD, 57701
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
97% worse than South Dakota average
South Dakota average: 3.3 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
75 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 13, 2025
Visit Reason
The inspection was conducted following a facility-reported incident involving a resident who sustained femur fractures after an improper transfer by certified nursing assistants and lack of assessment by a licensed practical nurse.
Complaint Details
The complaint investigation substantiated neglect by CNAs D and E for not following the resident's care plan and policy regarding gait belt use during transfer, and neglect by LPN F for not completing a physical assessment after notification. The resident sustained fractures to both femurs and later passed away.
Findings
The facility failed to protect a resident from neglect when two CNAs did not follow the resident's care plan or facility policy regarding gait belt use during transfer, resulting in fractures to both femurs. Additionally, an LPN failed to perform a physical assessment after being notified of the transfer. The incident was substantiated as neglect, and corrective actions were implemented.
Deficiencies (1)
Failure to protect resident from neglect by not following care plan and gait belt use during transfer, resulting in femur fractures.
Report Facts
Residents Affected: 1
Date of incident: Jul 27, 2025
Date survey completed: Aug 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in neglect finding for improper transfer |
| CNA E | Certified Nursing Assistant | Named in neglect finding for improper transfer |
| LPN C | Licensed Practical Nurse | Failed to perform physical assessment after transfer notification |
| LPN F | Licensed Practical Nurse | Failed to assess resident after notification and was suspended |
| RN J | Registered Nurse | Assessed resident after incident |
| Administrator A | Administrator | Confirmed neglect substantiation during interview |
| Director of Nursing B | Director of Nursing | Participated in interview regarding investigation |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Date: Jul 2, 2025
Visit Reason
The inspection was conducted based on a complaint intake by the South Dakota Department of Health regarding concerns about insufficient staffing during overnight shifts at the facility.
Complaint Details
The complaint was received on 2025-06-23 from an anonymous complainant concerned about insufficient staffing on overnight shifts. The complaint was substantiated by review of staffing records and interviews.
Findings
The provider failed to ensure that daily posted nurse staffing information was accurately updated to reflect the actual number of nursing staff and hours worked on three of four overnight shifts reviewed. Staffing shortages were noted during overnight shifts, with some licensed nurses and CNAs leaving early and not returning, resulting in fewer staff than needed to care for 75 residents.
Deficiencies (1)
Failure to update daily posted staffing information to reflect actual nursing staff numbers and hours worked on overnight shifts.
Report Facts
Residents: 75
Licensed nurses needed: 1
Licensed nurses needed: 2
CNAs needed: 3
CNAs needed: 4
LPN shifts worked: 12
CNA shifts worked: 8
Dates of staffing review: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding staffing issues and responsibility for updating staffing postings |
| Alzheimer's RN supervisor B | Registered Nurse Supervisor | Assisted with resident care during staffing shortages on 6/15/25 overnight shift |
| Former assistant director of nursing C | Assistant Director of Nursing | Assisted with resident care and staffing coordination on 6/15/25 overnight shift |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 27, 2025
Visit Reason
The inspection was conducted following complaints of physical abuse by a certified nursing assistant (CNA C) towards two cognitively impaired residents in the facility, reported on 1/2/25 and 2/25/25.
Complaint Details
The complaint investigation was substantiated for resident 2, with verified physical abuse by CNA C. The complaint for resident 1 was not substantiated. CNA C was suspended pending investigations and ultimately terminated after the second incident.
Findings
The investigation found that the allegations of abuse towards resident 1 were not verified, but the allegations towards resident 2 were verified, resulting in termination of CNA C's employment. The facility implemented corrective actions including staff education on abuse and neglect policies and increased supervision.
Deficiencies (1)
Failure to protect residents from physical abuse by a certified nursing assistant.
Report Facts
Residents affected: 2
Staff interviewed: 20
Staff interviewed: 12
Staff witnessed abuse: 4
BIMS score resident 1: 0
BIMS score resident 2: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Named in abuse allegations and investigations; suspended and terminated. |
| Administrator A | Administrator/Abuse Coordinator | Involved in investigation and notification. |
| Director of Nursing B | Director of Nursing | Supervised CNA C during investigation and involved in corrective actions. |
| Assistant Director of Nursing G | Assistant Director of Nursing | Supervised CNA C during investigation and involved in corrective actions. |
| Activity Director F | Activity Director | Reported abuse incident involving resident 2 and intervened. |
| CNA D | Certified Nursing Assistant | Witnessed abuse by CNA C towards resident 2. |
Inspection Report
Routine
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control standards, focusing on cleanliness and odor control in resident rooms, utility rooms, laundry, and equipment.
Findings
The facility failed to maintain a clean and odor-free environment in multiple areas including a soiled utility room, resident rooms, laundry room, clean utility room, and a urine-soaked chair in a resident's room. Observations revealed strong urine odors, soiled linens, overflowing garbage, dust buildup, leaking washer hose, and inadequate cleaning schedules. Staff interviews confirmed lack of cleaning schedules and delayed inspections.
Deficiencies (1)
Failure to maintain the environment and resident use items in a clean and odor-free condition, including soiled utility room, resident rooms, laundry room, clean utility room, and urine-soaked chair.
Report Facts
Residents Affected: Many
Number of washing machines: 2
Cleaning frequency: 1
Inspection frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper Q | Housekeeper | Interviewed regarding cleaning and mopping of resident rooms |
| Housekeeping Supervisor G | Housekeeping and Laundry Supervisor | Interviewed regarding cleaning of utility rooms, resident rooms, and laundry room |
| Certified Nursing Assistant M | CNA | Interviewed about soiled brown lift chair in resident 58's room |
| Director of Nursing B | Director of Nursing | Interviewed about expectations for staff regarding soiled chair |
| Infection Preventionist D | Infection Preventionist | Interviewed about expectations for staff regarding soiled chair |
Inspection Report
Routine
Deficiencies: 7
Date: Nov 7, 2024
Visit Reason
Routine inspection of Avantara Saint Cloud nursing home to assess compliance with regulatory requirements related to resident rights, privacy, environment, treatment, food service, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to dignity and privacy, inadequate maintenance and cleanliness of resident rooms and common areas, failure to provide physician-ordered treatments and supplies, unsanitary kitchen and food service practices, and poor infection prevention and control measures.
Deficiencies (7)
Failure to honor resident's right to a dignified existence, self-determination, communication, and to exercise rights, including improper clothing and labeling of socks for resident with severe cognitive impairment.
Failure to provide diabetic fingernail care as ordered, with long, caked fingernails and lack of documentation.
Failure to ensure privacy and confidentiality, including window coverings that did not protect privacy, unsecured electronic medical records, and unlocked medication cart with visible resident information.
Failure to maintain a clean and homelike environment with multiple resident rooms having exposed sheetrock, missing paint, damaged walls, broken outlet covers, and soiled privacy curtains.
Failure to provide appropriate treatment and care according to physician orders, including residents not wearing TED hose, Redi-Wraps, or compression stockings as ordered.
Failure to maintain kitchen and dishroom in a clean and functional manner, including lime build-up on cups, unclean plate warmer, stained measuring cup, dirty knife holder, broken light cover, expired sanitizer test strips, dusty air conditioner, improper handling of insulated plate covers, and uncovered food during transport.
Failure to provide and implement an infection prevention and control program, including strong urine odors in secured unit and resident rooms, soiled utility room with overflowing containers, dirty laundry room with leaking washer and dripping pipe, stained shoes in clean utility room, and urine-soaked chair in resident room.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 14
Residents affected: 8
Residents affected: 5
Residents affected: 6
Residents affected: 3
Residents affected: 16
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide K | Certified Nurse Aide | Interviewed regarding resident 8's clothing and resident 31's fingernail care |
| Assistant Director of Nursing C | Assistant Director of Nursing | Interviewed regarding resident 31's wound care and fingernail care |
| Hospice Registered Nurse L | Hospice Registered Nurse | Interviewed regarding resident 31's wound care and fingernail care |
| Director of Nursing B | Director of Nursing | Interviewed regarding nail care policy, privacy issues, and ordered treatments |
| Registered Nurse J | Registered Nurse | Observed medication pass and interviewed regarding ordered treatments |
| Food Service Manager E | Food Service Manager | Interviewed regarding kitchen cleanliness and food transport practices |
| Dietary Aide O | Dietary Aide | Observed food transport and handling practices |
| Housekeeping Supervisor G | Housekeeping Supervisor | Interviewed regarding cleaning schedules and utility room conditions |
| Interim Maintenance Supervisor H | Interim Maintenance Supervisor | Interviewed regarding maintenance and repair of resident rooms |
| Certified Nursing Assistant M | Certified Nursing Assistant | Interviewed regarding soiled chair in resident 58's room |
| Qualified Activity Director F | Qualified Activity Director / Central Supply Staff | Interviewed regarding supply shortages of ordered compression stockings and wraps |
| Infection Preventionist D | Infection Preventionist | Interviewed regarding infection control expectations |
Inspection Report
Routine
Deficiencies: 7
Date: Oct 26, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, pressure ulcer care, mental health treatment, and other regulatory requirements at Avantara Saint Cloud nursing facility.
Findings
The facility failed to ensure professional standards of care in medication administration, insulin injection technique, and documentation of deceased residents. There were deficiencies in pressure ulcer care, including failure to provide ordered pressure-relieving equipment and inaccurate wound staging. The facility also failed to properly assess, document, and intervene for a resident with suicidal ideation according to their policy.
Deficiencies (7)
Medication administration practices by an LPN were not in compliance for multiple residents, including improper handling and preparation of medications.
Physician's orders for Tylenol were not written to eliminate dose calculation by an unlicensed medication aide.
Insulin administration technique was incorrect; needle was withdrawn too soon.
Deceased resident's note was missing from medical record.
Failure to follow up on dental appointment for a resident needing a new lower partial denture.
Failure to provide physician-ordered ROHO cushion and air mattress for a resident with pressure ulcer, and inaccurate staging of pressure ulcer.
Failure to assess, document, and provide interventions per policy for a resident with suicidal ideations, including lack of notification to physician and lack of suicide precautions.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Pressure ulcer measurements: 1
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 1
Braden scale score: 16
Brief Interview of Mental Status score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN H | Licensed Practical Nurse | Named in medication administration deficiencies. |
| LPN F | Licensed Practical Nurse | Named in insulin administration deficiency and denture care interview. |
| UMA I | Unlicensed Medication Aide | Named in medication administration deficiency. |
| Director of Nursing A | Director of Nursing | Interviewed regarding medication administration, denture care, deceased resident documentation, and mental health deficiencies. |
| Assistant Director of Nursing K | ADON/Infection Preventionist/Wound Care Nurse | Named in pressure ulcer care deficiencies. |
| Wound Care Certified Nurse Practitioner L | Wound Care Certified Nurse Practitioner | Consulted on resident's pressure ulcer care. |
| Director of Rehabilitation D | Director of Rehabilitation | Interviewed regarding ROHO cushion availability and notification. |
| Maintenance Director M | Maintenance Director | Interviewed regarding air mattress availability and notification. |
| Social Service Designee E | Social Service Designee | Interviewed regarding dental appointment follow-up and suicidal ideation process. |
| Nurse Supervisor/Charge Nurse | Referenced in suicide threat policy procedures. | |
| CNA J | Certified Nursing Assistant | Observed resident behavior related to suicidal ideation. |
| Nurse Supervisor/Charge Nurse | Referenced in suicide threat policy procedures. | |
| Regional Nurse Consultant C | Regional Nurse Consultant | Interviewed regarding deceased resident documentation and pressure ulcer care. |
| Nurse Supervisor N | Nurse Supervisor | Interviewed regarding pressure ulcer care communication. |
| Interim Administrator B | Interim Administrator | Interviewed regarding deceased resident documentation and pressure ulcer care. |
Inspection Report
Routine
Census: 15
Deficiencies: 8
Date: Aug 31, 2022
Visit Reason
Routine inspection of Avantara Saint Cloud nursing home to assess compliance with resident dignity, environment, care practices, infection control, and other regulatory requirements.
Findings
The inspection identified multiple deficiencies including failure to treat residents with dignity during meals, inadequate maintenance of facility environment, lack of clean linens, improper wheelchair maintenance, unsafe resident transfers, failure to maintain palatable food temperatures, incomplete hospice care planning, and lapses in infection prevention practices.
Deficiencies (8)
Failure to ensure 15 residents were treated with dignity and respect during meals by a certified nurse aide who did not interact with residents while waiting for meal service.
Failure to maintain a safe, clean, comfortable, and homelike environment including chipped paint, scuff marks, unpainted drywall repairs, and broken closet doors in multiple resident rooms and hallways.
Lack of clean fitted bed sheets and pillow cases in multiple resident rooms, and inadequate routine cleaning and maintenance of wheelchairs and dining rooms.
Unsafe resident transfers including use of bear hug technique without gait belt and leaving a resident at risk for falls unattended at the edge of the bed during personal care.
Failure to serve food at palatable temperatures; food was observed to be cold after prolonged uncovered exposure and no microwave was available in the dining room for warming food.
Failure to develop and maintain an integrated hospice care plan for a resident receiving hospice services, lacking directives for hospice service types, frequency, and utilization.
Inadequate infection prevention and control practices including improper cleaning of shared vital sign equipment, improper glove use and hand hygiene, and uncovered transport of clean linen.
Inappropriate bed bathing technique using the same washcloth and water for washing and rinsing a resident.
Report Facts
Residents observed during meal dignity observation: 15
Wheelchairs observed with cleanliness issues: 10
Resident rooms with maintenance issues: 12
Residents with bare mattresses: 5
Temperature of spaghetti served: 87.2
Temperature of Cream of Wheat cereal: 112.8
Temperature of pureed eggs: 97.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA I | Certified Nurse Aide | Named in dignity during meal observation and unsafe bed bath and fall risk supervision |
| CNA L | Certified Nurse Aide | Named in unsafe resident transfer without gait belt |
| Director of Nursing B | Director of Nursing | Interviewed regarding staff expectations, transfer training, and hospice care plan |
| Regional Nurse Consultant D | Regional Nurse Consultant | Interviewed regarding staff expectations and observations |
| Activity Director E | Activity Director | Observed entering dining room and encouraging music |
| Maintenance Director F | Maintenance Director | Interviewed regarding facility maintenance and staffing |
| Dietary Manager G | Dietary Manager | Interviewed regarding food temperatures and meal service |
| Laundry Supervisor H | Laundry Supervisor | Interviewed regarding linen availability and laundry processing |
| Assistant Director of Nursing/Infection Control Nurse C | Assistant Director of Nursing/Infection Control Nurse | Interviewed regarding infection control practices and meal assistance |
| Physical Therapy Assistant O | Physical Therapy Assistant | Interviewed regarding transfer training and gait belt use |
| Administrator A | Administrator | Interviewed regarding facility maintenance, staffing, and infection control |
| CNA J | Certified Nurse Aide | Interviewed regarding clean linen transport practices |
| Registered Nurse/Alzheimer Director N | Registered Nurse/Alzheimer Director | Interviewed regarding hospice care plan location |
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