Avantara Huron

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, record review, interview, and policy review, the provider failed to ensure resident safety and supervision for one of one cognitively impaired sampled resident (1) identified at risk for elopement (leaving the facility without staff knowledge), was to be monitored and redirected when near exits and was seen outside the facility, walking down the street by a community member, who notified the facility. The resident was located over two blocks away from the facility, walking on the sidewalk, by licensed practical nurse (LPN) D. Failure to adequately supervise and redirect the resident may have contributed to the resident's elopement placing the resident at risk for an accident and/or injury while she was out of the building and unsupervised. [...]

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) complaint report, interview, document review, record review, and policy review, the provider failed to protect the resident's right to be free from sexual abuse by one of one certified nursing assistant (CNA) (D) for one of two sampled resident (57) who reported she was touched in a private area without her consent. And by one of one unidentified staff member for one of two sampled resident (78) who reported she was touched in a private area without her consent. Immediate Jeopardy (IJ) at F600, severity J., began on 3/11/26 at 11:40 a.m. when resident 57 revealed in an interview that she had a concern about being touched by a staff member on 1/23/26 during the night rounds. [...]

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) complaint report review, interview, document review, record review, and policy review, the provider failed to ensure two of two sampled residents' with expressed feelings of emotional distress (57 and 78) allegations of sexual abuse reported to social services designee (F) regarding having been touched in their private areas without the residents' consent by one of one certified nursing assistant (CNA) (D) and an unidentified staff member were thoroughly investigated to prevent further emotional distress, further staff-to-resident sexual abuse or to mitigate the risk of sexual abuse.

Inspectors wroteBased on the interview, record review, call light log documentation review, and policy review, the provider failed to ensure staff responded promptly to two of four sampled residents (30 and 82) who indicated they had concerns with the call lights not being answered in a timely manner. Resident 82 reported being in pain while waiting for her call light to be answered, and Resident 30 reported urinary incontinence when having to wait for her call light to be answered. Findings Include:1. Interview on 3/8/26 at 2:03 p.m. and 3/9/26 at 10:42 a.m. with resident 30 revealed she had concerns that the facility was short of staff, staff were quitting, and the facility needed to use contracted travel staff. She had concerns that her call light sometimes was not answered quickly enough, causing her to incontinent of urine. 2. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (7) who eloped (left the facility without staff knowledge) from the front door of the facility on 9/2/25, and one of one sampled resident (77) who fell while being transferred by certified nursing assistant (CNA) V, who did not transfer the resident as directed in the resident's care plan (personalized plan that addresses a resident's care needs, goals, and interventions). This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incidents. Findings Include:1. Review of the provider's 9/3/2025 SD DOH FRI revealed on 9/2/25 at 2:48 p.m. [...]

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) complaint report review, interview, document review, record review, and policy review, the provider failed to implement policies and procedures to report to the SD DOH and law enforcement, allegations of sexual abuse for two of two sampled residents (57 and 78) who reported sexual abuse allegations to social service designee (SSD) (F) that they were touched in their private area by one of one certified nursing assistant (CNA) (D) and an unidentified staff member. The provider's failure to report those allegations to law enforcement for review and investigation may have put those residents at continued risk for further abuse and all residents at risk for potential abuse.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure:*Food was maintained at a safe temperature to prevent food-borne illness for one of two observed meal services in one of two dining rooms (Independence).*Ten of eleven observed staff (B, C, D, F, O, HH, II, JJ, KK, and LL) who washed their hands in the Independence kitchenette with food uncovered, without hair restraints to prevent hair from contacting the food, during an observed supper meal service.*Four of five observed staff (C, G, NN, OO) who washed their hands in the [NAME] kitchenette with food uncovered, without hair restraints to prevent hair from contacting the food during an observed lunch meal service.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to notify the physician of two of three sampled residents (57 and 61) who had unplanned significant weight loss (a loss of 5% (percent) of body weight in 30 days, 7.5% in 90 days, or 10% in 180 days).

Inspectors wroteBased on record review, interview and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, the provider failed to ensure three of five sampled residents' (7, 10, and 57) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop and individualized care plan to manage the resident's care needs) assessments were accurately coded for the areas of medications and Pre-admission Screening and Resident Review (PASRR).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to complete a Level II (2) Preadmission Screening and Resident Review (PASRR) for one of one sampled resident (32) with a new psychosis diagnosis. Findings Include: 1. Review of resident 32's electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and had a diagnosis of unspecified psychosis that was documented on 1/23/26.2. Resident 32's 1/19/26 PASRR level 1 screening form did not a indicate a confirmed or suspected mental illness diagnosis.3. Interview on 3/11/26 at 12:45 p.m. with social services designee (SSD) F revealed that she did not complete a PASRR level 2 on resident 32. The nursing staff was to let her know if there was an update in the residents' diagnoses within the facility. SSD F was not aware if the nursing staff informed her of resident 32's psychosis diagnosis.4. [...]

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure the resident's baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was complete within 48 hours of the resident's admission to the facility for two of five newly admitted sampled residents (42 and 56).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the residents' care plans (personalized plan that addresses a resident's care needs, goals, and interventions) were reviewed and revised to reflect the current care needs for three of twenty sampled residents (10, 32, and 84).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the staff followed infection prevention and control practices by: *Not having personal protective equipment (PPE) (gloves and gowns) available for staff use for two of two sampled residents (82 and 84) on enhanced barrier precautions (using gowns and gloves during high-contact care to reduce the spread of multidrug-resistant organisms (MDROs) in a nursing home).*One of one observed certified nursing assistant (CNA) (EE) while providing urinary catheter (flexible tubing placed in the bladder to drain urine) care for one of one sampled resident (20).*One of one observed licensed practical nurse (LPN) (G) who did not perform hand hygiene (handwashing) while completing one of one sampled resident's (20) wound care treatment. Findings Include:1. Observation on 3/8/26 at 2:13 p.m. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), observation, interview, record review, and policy review, the provider failed to protect residents from neglect by: A. CNA Z who did not provide nighttime cares for one of one sampled resident (425) who was observed the following morning in her clothing from the previous day and incontinent of bowel.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to maintain clean and sanitary conditions in one of one observed kitchen where residents' food was stored and prepared.

Inspectors wroteA. Based on observation, interview, record review, policy review, and manufacturer's recommendations, the provider failed to ensure one of two observed ice machines were maintained in a clean and sanitary manner.

Inspectors wroteBased on record review, interview, and policy review the provider failed to ensure: *Fourteen of twenty-nine residents (10, 23, 46, 49, 53, 55, 64, 65, 67, 70, 224, 274, 375 and 424) had received a summary of their baseline care plan. *One of one sampled resident (424) had a baseline care plan completed within forty-eight hours of admission.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to provide bed-hold notice to the resident and/or their representative regarding the transfer to a hospital for one of one sampled resident (5) for two of three occasions.

Inspectors wroteBased on observation, interview, record review and policy review the provider failed to ensure the timely review and revision of one of one (424) sampled resident's care plan.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure adequate pain management for one of one sampled resident (375) who expressed she had pain.

Inspectors wroteBased on interview, record review and policy review the provider failed to ensure one of one sampled resident (67) who required dialysis treatment was monitored for abnormalities upon returning from his dialysis treatment.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure the range hood vents, ice machine, and ceiling tiles were maintained in a clean condition in one of one kitchen.