Avantara Mountain View

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 protect the residents' right ro be free of misappropriation of property by one of one certified nurse aide (CNA)/qualified medication aide (QMA) (D) who agreed to cash one of one sampled resident's (2) scratch tickets in exchange for half of the winning money amount and who took one of one sampled discharged resident's (1) medication for her personal use. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

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 a resident received the necessary behavioral health services to treat a diagnosed serious mental illness and to identify and implement interventions and effective communication processes with other healthcare entities to mitigate the resident's risk for self-harm for one of one sampled resident (2) with diagnosed mental health illness who attempted suicide with a call light cord.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to report incidents to the SD DOH within the required time frame, for one of one sampled resident (3) who reported to registered nurse (RN) E that his wound was caused by his bed frame, one of one sampled resident (4) who was allegedly abused by certified nursing assistant (CNA) M and was not reported until two weeks later by CNA P, one of one sampled resident (5) who was involved in a relationship with one of one licensed practical nurse (LPN) (J), and one of one sampled resident (2) who attempted suicide.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, employee record review, and policy review, the provider failed to protect the resident's right to dignity and respect when one of one certified nursing assistant (CNA) U used her phone to record a video in the shower room while one of one CNA (S) verbally abused one of one resident (1) who was taking a shower.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), interview, record review, and policy review, the provider failed to ensure a physician's antibiotic medication order was accurately entered into the resident's electronic medical record (EMR) by one of one registered nurse (RN) (H) for one of one sampled resident (3) who did not receive his antibiotic until a day after it was prescribed and needed his left foot's fifth toe amputated due to an infection. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to identify and implement specific care approaches that addressed the mental and psychosocial needs of one of one sampled resident (3) with diagnosed post-traumatic stress disorder, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event (PTSD) and one of one sampled resident (2) who had experienced a traumatic event to mitigate trauma triggers and prevent re-traumatization.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure the staff followed professional standards of practice to ensure:*The resident's physician was notified that one of two sampled residents (31) with physician's orders for dialysis treatments refused four of those treatments from 12/5/25 through 12/31/25.*One of one observed certified medication aide (CMA) (L) administered medications according to the physician's order to ensure the full dose was given for one of one sampled resident (34) with orders for lactulose laxative medication.*One of one sampled resident's (57) insulin was administered according to the physician's order by one of one licensed practical nurse (LPN) (I).*Documentation supported that one of one sampled resident's (86) WanderGuard (a wearable door alarming device) was checked each shift to ensure it was on the resident's [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), interview, record review, and policy review, the provider failed to ensure residents received quality of care for:One of one sampled resident (18) who was not repositioned and provided continence care for approximately nine hours by two of two certified nursing assistants (CNA) (U and V) between 7/18/25 and 7/19/25. One of one sampled resident (64) whose care plan was not followed by one of one CNA (S) on 12/7/25. One of one sampled resident (23) who was not provided timely continence care by one of one CNA (P) on 1/1/26. This citation is considered past non-compliance after review of the corrective actions the provider implemented following those incidents.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the staff followed infection prevention and control practices regarding: *Hand hygiene (handwashing) and glove use by two of two certified nursing assistants (CNA) (D and E) observed assisting one of one sampled resident (2) with transferring, using a full body mechanical lift (a lift and sling used to lift a person's full body). *Hand hygiene and glove use by one of one wound care registered nurse (RN) (F) observed performing a wound dressing change for one of one sampled resident (2). *Hand hygiene and glove use by one of one licensed practical nurse (LPN) (I) observed cleaning a resident's glasses and administering liquid nutritional formula through a feeding tube for one of one sampled resident (5). [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (34) observed with a medication left at her bedside was evaluated for her ability to safely self-administer that medication.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the staff protected the residents' right to privacy and confidentiality of their protected health information in their electronic medical records (EMR) that was displayed and viewable to anyone who passed by.

Inspectors wroteA. Based on observation, interview, and policy review, the provider failed to adhere to professional standards of care practice and their facility's process for the accountability of controlled (risk for mental or physical dependence) medications by one of one registered nurse (RN) (I) and two of two licensed practical nurses (LPN) (S and P) who had signed the accounting of controlled medications sheet before a physical inventory of those medications with the oncoming nurse had occurred.

Inspectors wroteBased on interview, record review and policy review the provider failed to ensure three of three sampled residents (26, 33, and 85) who required dialysis treatment were monitored for abnormalities upon returning from their dialysis treatments.

Inspectors wrote2. Observation on 12/11/24 at 7:59 a.m. revealed resident 29's nebulizer medicine cup was sitting on her bedside table and contained a clear liquid. Review of resident 29's MAR revealed her morning nebulizer treatment was documented as administered. Interview on 12/11/24 at 11:20 a.m. with resident 29 revealed she: *Had not received her morning nebulizer treatment. *Stated she had been busy during the morning and when she returned to her room, she could not reach the button to start her nebulizer treatment. Interview on 12/11/24 at 11:32 a.m. with director of nursing (DON) D in resident 29's room revealed: *Resident 29 had told DON D she had not had her morning nebulizer treatment. *DON D confirmed the clear liquid in resident 29's nebulizer medicine cup was her morning nebulizer treatment. Continued interview on 12/11/24 at 11:37 a.m. with DON D revealed: [...]

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure: *One of one sampled resident's (74) prescription Ativan (anti-anxiety medication) was accurately labeled. *Outdated medical supplies had been removed from two of two observed medication storage rooms. *One of one sampled resident (50) had a pharmacy label on his aspart insulin pen. *Two of two sampled residents (18 and 85) opened aspart insulin pens were not available for use after the expiration period.

Inspectors wrote2. Observation and interview on 12/10/24 at 10:57 a.m. with resident (54) while in her room revealed: *She was lying on her right side under a blanket. *She stated she had a skin concern under [her] tummy but the nurses were addressing that. Interview on 12/11/24 at 7:49 a.m. with registered nurse (RN) N revealed she stated: *Resident 54 had a yeast infection in her groin area, under her breasts, and her left underarm area. *They were treating this infection by washing and powdering the areas two times a day. Observation on 12/11/24 at 8:23 a.m. of resident 54's personal care and treatment of her yeast infection while in her room revealed: *RN N washed her hands for about five seconds before putting on gloves and then performed personal care for resident (54) with soap, water and a washcloth. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (26 and 51) had their care plans followed, updated, and revised promptly to reflect their current status and care needs.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), interview, record review, and policy review, the provider failed to ensure one of two facility operated buses had functional straps to safely secure one of one sampled resident's (26) wheelchair while being transported from another location. Failure to ensure the straps were functional and the wheelchair was safely secured potentially placed the resident at risk for harm or injury. This citation is considered past-non-compliance based on a review of the corrective action the provider implemented following the incident.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure one of one sampled resident (68) who received an antibiotic for a potential urinary tract infection (UTI) had met clinical criteria for the use of that antibiotic.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure adequate pain management for one of one sampled resident (1) who inflicted harm to himself that required surgical treatment at a hospital. Failure to assess and provide adequate pain control may have contributed to resident 1's action of self-harm. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on observations, interview, record review, and policy review the facility failed to ensure infection prevention and control practices were implemented for the following: *Continuous positive airway pressure (CPAP) tubing was cleaned once a week for one of one sampled resident (12). *Appropriate hand hygiene and glove use during: -A dressing change for one of one sampled resident (14). -Personal care provided for two of two sampled residents (29 and 74) by two of three certified nurse aides (CNAs) (D and F). -Medication administration performed by one of two licensed practical nurses (LPN) (E) for one of two residents (2).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the following: *One of one sampled resident's (48) medications were not left on her over-the-bed table by one of one licensed practical nurse (LPN) (E) without ensuring the resident had taken those medications. *One of one LPN (E) had not documented one of one sampled resident's (48) medications were administered without having observed the resident take those medications. *One of one LPN (H) had not documented she had administered one of one sampled resident's (68) medications were prepared and administered by one of one unlicensed medication aide (UMA) (I).