Avantara Milbank

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure the staff followed standard food service sanitation practices in one of one kitchen, where residents' meals were prepared and served, regarding the dishwashing machine not reaching the minimum temperature for the wash cycle, the crumbling wall behind the dishwasher, and the cleanliness of the food preparation areas, the two handwashing sinks, the clean dish areas, the dishwasher, and the light coverings.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure the staff followed the care planned interventions for one of one sampled resident (2) who expressed distress and reported allegations of abuse when one of one certified nursing assistant (CNA) (P) did not provide the resident's care with another staff member present, as identified in his care plan and the provider failed to provide necessary behavioral health care and services to support the resident's highest practicable mental, emotional, and psychosocial well-being.

Inspectors wroteBased on a South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure that residents were free of significant medication errors for one of one sampled resident (3) who admitted to the facility following a hospitalization for surgical repair of a fractured left hip and did not receive Aspirin 81 milligrams (mg) twice daily as ordered from the 12/19/25 p.m. dose through the 1/18/26 p.m. dose. Following that medication error, resident 3 experienced increased pain, spontaneous bruising, and increased swelling in her lower legs, which required medical intervention and developed Deep Vein Thrombosis (DVTs) (a blood clot that forms in a vein deep inside the body, most commonly in the lower leg or thigh) in both of her lower legs.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to protect the resident's rights for one of one sampled resident (2) who was not provided a copy of his resident rights, or could exercise his rights without interference, when staff members took away his personal possessions (his tattoo gun, his vape, and his computer), and failed to honor his requests for privacy and staff boundaries as documented in his care plan.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incidents (FRIs), personnel files, record review, observation, interview, and policy review, the facility failed to protect the residents' property for one of one sampled resident (4) who had 13 Hydrocodone/APAP (acetaminophen) (a narcotic medication to treat moderate to severe pain) 5-325 milligram (mg) tablets go missing by one of one contracted travel registered nurse (RN) (N) and one of one sampled resident (5) who had one lorazepam (a medication to treat anxiety) 0.5 mg tablet found missing by licensed practical nurse (LPN) L and contracted travel LPN (T) and was not found.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, observation, and policy review, the provider failed to ensure: residents received quality care when one of one certified nursing assistant (CNA) H applied Nair (chemical hair removal cream) cream to one of one sampled resident's (2) anal area and inner buttocks who did not have a physician's order for the use of that cream and subsequently sustained a chemical skin burn; and ensure call lights were answered timely for four of six sampled residents (1, 6, 11, and 13) who reported having to wait a long time for the staff to answer their call lights.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), record review, interview, observation, and document review, the provider failed to ensure the safety for one of one resident (10) who spilled coffee on his hand and leg that was not at safe temperature, two of seven observed residents (11 and 12) who were drinking hot liquids and did not have identified safety inventions followed, and for one of one sampled resident (8) who fell in the shower when certified nursing assistant (CNA) (AA) did not follow his care plan (personalized plan that addresses a resident's care needs, goals, and interventions).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incidents (FRIs), personnel files, record review, observation, interview, and policy review, the facility failed to ensure safe and secure storage of controlled medications (medications with risk for abuse and addiction) for one of one sampled resident (4) with 13 missing Hydrocodone /APAP (acetaminophen) (a medication to treat moderate to severe pain) 5-325 milligram (mg) tablets and one of one sampled resident (5) missing one lorazepam (a medication to treat anxiety) 0.5 mg tablet.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, document review, record review, and policy review, the provider failed to report within the required time frame for one of one sampled resident (1) who eloped (left the facility without staff knowledge) from the facility's front door.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure the staff followed the resident's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) for:*One of one sampled resident (14) who was transferred from his wheelchair to the commode (portable toilet) by one of one certified nursing assistant (CNA) GG when he required the assistance of two staff members.*One of one sampled resident (2) who required two staff members present during all of his cares and was assisted by one of one CNA (P), and an accusation of resident abuse was made.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to provide wound care as ordered by the physician for one of one sampled resident (9) who had a wound vac (a device that uses negative pressure to remove excess fluid and debris from a wound to promote wound healing) dressing that was not changed as prescribed by the physician by one of one registered nurse (RN) (R) and needed emergent medical attention.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) Facility Reported Event (FRI), SD DOH complaint report, record review, interview, professional reference review, and policy review, the provider failed to provide appropriate enteral (passing through the digestive tract) feeding care regarding using a new enteral feeding bag for administering formula and safely storing nutritional formula for one of one sampled resident (7) who received nutritional formula through a feeding tube (a tube surgically placed through the abdomen into the stomach to administer liquid nutrition, fluids and medications) when an enteral feeding bag was not replaced with a new bag for administration of nutritional formula to the resident when a new bag was not found by the director of nursing (DON) B.

Inspectors wroteBased on a South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure that procedures were implemented to process medication orders to ensure medications were administered accurately for one of one sampled resident (3) who admitted to the facility following a hospitalization for surgical repair of a fractured left hip and did not receive Aspirin 81 milligrams (mg) twice daily as ordered from the 12/19/25 p.m. dose through the 1/18/26 p.m. dose after the order was incorrectly entered into the provider's electronic order system (PCC) by the pharmacy. [...]

Inspectors wroteBased on observation, interview, and policy review, the provider failed to follow acceptable food service standards and their policies to ensure one of one kitchen was maintained in a clean and sanitary condition, and proper glove use by cook/dietary aide (J) while preparing and serving residents' food during one observed meal service.

Inspectors wroteBased on observation, interview, record review, resident council review, and policy review, the provider failed to ensure prompt response to call lights and necessary care and services were provided for six of six residents (5, 8, 9, 15, 23, and 285) and one of six additional resident council meeting residents (18) to maintain their physical, mental, and emotional well-being. Those residents expressed frustration related to the delay in staff response to their call lights and requests for assistance.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, interview, observation, manufacturer's manual review, and policy review, the provider failed to ensure resident safety by improper use of lift equipment as directed in the residents' care plans and/or the lift manufacturer's manual for: *One of two sampled resident (9) who required the assistance of two staff for transfers with a lift, who was lowered to the floor while being transferred with the use of a mechanical sit-to-stand lift (a mechanical lift that requires the person to partially bear weight on at least one leg when assisted from a seated position to a standing position) by one certified nursing assistant (CNA) (K) without the assistance of another qualified staff person. [...]

Inspectors wroteBased on record review and interview, the provider failed to notify or provide a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman for three of three sampled residents (2, 9, and 186) who were hospitalized after admission to the facility.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to provide bed-hold notices to the resident or the resident's responsible party at the time of transfer to a hospital for three of three sampled residents (2, 9, and 186) who were hospitalized after admitting to the facility.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint online report, interviews, records review, and policy review, the provider failed to ensure one of one resident (1) had been free from a significant medication error when he was administered two long-action insulins at the same time for four consecutive days.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and policy review, the provider failed to follow their grievance policy regarding a complaint filed by a family member on behalf of resident 2 who had received services from the facility. Findings revealed: 1. Review of the provider's 8/14/24 SD DOH FRI revealed: *On 8/14/24 the daughter of resident 2 had voiced concerns regarding services provided to her mother (resident 2) which included the following: -Potential staff improper use of mechanical lifts with resident transfers which may have resulted in resident 2 having a dislocated hip that was later discovered while she was hospitalized . -Short staffing. -Long call light wait times. -A COVID-19 positive resident wandering the facility and possibly infecting others. -Resident 2 had symptoms of black/tarry bowel movements. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint online report, document review, interview, and policy review, the provider failed to provide report to the SD DOH for one of one sampled resident (1) who was given two long-acting insulins at the same time for four days, had episodes of hypoglycemia (low blood sugars), and required evaluation at the emergency department (ED).

Inspectors wroteBased on a 10/7/24 complaint intake report review, interview, record review, and policy review. The provider failed to ensure a thorough investigation was completed to rule out if abuse and neglect occurred for one of one sampled resident (1) who had bruising and swelling of unknown origin on the left knee, right wrist, and penis and to report the incidents to the South Dakota Department of Health.

Inspectors wroteBased on a 10/7/24 complaint intake report review, interview, record review, and policy review. The provider failed to ensure a thorough investigation was completed to rule out if abuse and neglect occurred for one of one sampled resident (1) who had bruising and swelling of unknown origin on the left knee, right wrist, and penis and to report the incidents to the South Dakota Department of Health.

Inspectors wroteBased on complaint intake report review, record review, observation, interview, and policy review. The provider failed to ensure adequate fluid intake, monitoring, and interventions for 6 of 6 sampled residents [1, 2, 3, 4, 5, & 6] resulting in dehydration and hospitalization for one of six sampled residents [1].

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure activities of daily living (ADL) tasks were performed and accurately documented for four of four sampled residents (1, 2, 3, and 4) who were dependent on staff assistance.

Inspectors wroteA. Based on observation, interview, and record review, the provider failed to clarify one of one sampled resident's (35) medication dosage from a physician's order which resulted in the resident receiving 8 times the intended prescribed dose of an antipsychotic medication for 14 days, which potentially contributed to his increased lethargy during that time.

Inspectors wroteBased on interview, observation, record review, and policy review, the provider failed to adequately assess one of four resident's (43) ability to safely smoke unsupervised that resulted in the resident falling outside on two separate occasions and sustaining head injuries.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to: *Offer to assist one of one sampled resident (25) with cleaning his face and changing his clothes when there were visible food stains on them. *Maintain privacy for two of two sampled residents (3 and 16) during bathing and toileting care. *Assist three sampled dependent residents (16, 27, and 35) to the dining room in a timely manner.

Inspectors wroteBased on record review, observation, interview, and policy review, the provider failed to develop and implement a comprehensive person-centered care plan for three of sixteen sampled residents (21, 25, and 30). Specifically, the provider failed to include focused goals, interventions, and services related to: *Skin integrity, bowel and bladder function, and pain for resident 21. *Smoking, therapy, prosthetic use and appropriate footwear, and advanced directives for resident 25. *Behaviors for resident 30.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure infection control practices were followed for the following: *Two of two staff (administrator A and cook M) who kept their personal beverages in the food preparation areas. *One of one observed certified nursing assistant (CNA W) who coughed into her arm and continued serving food without performing hand hygiene. *One of three food service staff (cook M) had worn gloves and performed hand hygiene while preparing and serving food.