Avantara North

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed regarding the residents' nasal cannulas being dated and stored in plastic bags when they were not in use for four of four sampled residents (1, 9, 11, and 15) who required the use of oxygen, and one of one sampled resident (11) who used a nebulizer (a device that converts liquid medication into an inhalable mist) machine that was not cleaned after each use by the nursing staff.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure professional standards were met regarding one of one sampled resident (64) who was not prescribed a dose amount for his lidocaine (pain) medication by his physician, and two of two registered nurses (RN) (E and F) administered that medication without knowing the recommended amount.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake review, record review, interview, and policy review, the provider failed to:Ensure there was a physician's order for one of one closed record sampled resident's (1) urinary catheter. Ensure there was a documented clinical indication for urinary catheter use by one of one closed record sampled resident (1) that included a physician's order for catheter removal when it was no longer clinically indicated. Identify and implement measures to mitigate of one of one closed record sampled resident (1) with a urinary catheter from developing a urinary tract infection.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake review, record review, interview, and policy review, the provider failed to ensure:During a June 2025 facility COVID-19 outbreak, all residents' COVID-19 testing and test results had been appropriately documented per the provider's policy. Prior to discharge of one of one closed record sampled resident (1) to another nursing home on 6/18/25, the receiving nursing home received disclosure of a COVID-19 outbreak at the provider's nursing home. Accurate and appropriate documentation of the administration of one of one closed record sampled resident's (1) second step of a 2-step tuberculosis (TB) test was conducted.

Inspectors wroteBased on a South Dakota Department of Health (SD DOH) complaint review, interview, record review, and policy review, the provider failed to follow their policy to ensure one of one closed record sampled resident's (1) discharge plan was documented and appropriate information was communicated to the nursing home that had accepted that resident for admission.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and policy review, the provider failed to ensure one of one closed record sampled resident (1) had documentation to support physician-ordered oxygen was arranged and provided for her to use while being transported from the provider's facility to another nursing facility where she had been accepted for admission.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and record review, the provider failed to validate the status of one of one social services designee's (SSD) (G) temporary nursing license while she was employed in that capacity between February 2025 and May 2025. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure residents' prepared food was served and distributed in a palatable manner during two of two observed meal services.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to effectively implement and ensure appropriate and necessary infection prevention and control practices were followed: *When one of one observed licensed practical nurse (LPN) (F) did not wear a mask during a facility acknowledged respiratory outbreak. *When the use of appropriate enhanced barrier precautions (EBP) was not followed by one of one certified nurse aide (CNA) (H) during personal care for one of one sampled resident (7) on EBP. *When appropriate hand hygiene and glove use was not followed by one of one CNA (G) during personal care for one of one sampled resident (1). *For the cleaning of shared resident equipment by CNAs (H and I) after use by one of one sampled resident (45) on EBP. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to protect the residents' right to be cared for with respect and dignity for: *One of one sampled resident (6) by one of one certified therapy assistant (COTA) (K). *One of one sampled resident (32) who had a container for rinsing his colostomy bag stored on his bedside table in full view of others.

Inspectors wroteBased on a South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and personnel file review, the provider failed to ensure one of one sampled resident (35) was free from physical restraint by two of two certified nursing aides (CNA) (M and Q) and one of one licensed practical nurse (LPN) (R) who physically held down the resident's lower extremities while they provided his personal care. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to document one of one sampled resident's (1) disrobing behavior that supported her continued need to have a dignity curtain placed inside of her room.

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 the safety for: *One of one sampled resident (1) who staff assisted out of the building in the early afternoon hours, left the facility grounds without staff knowledge, was returned to the facility by an unknown individual, was not appropriately assessed for potential harm, and his physician was not notified timely of the incident. *One of one sampled resident (2) whose care plan was not followed by staff who were to provide her supervision while she was in her wheelchair with a safety belt around her lap. This citation is considered past non-compliance based on review of the corrective actions the provider implemented following the incidents.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), interview, record review, policy review, the provider failed to ensure their policy related neglect reporting had been followed regarding an incident of elopement for one of one sampled resident (1). This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the managements knowledge of the elopement.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to: *Maintain the cleanliness of the following kitchen equipment: -The dishwasher. -The microwave. -The reach-in ice machine. -The tabletop in which the beverage machines were located. -The flattop grill and stove backsplash. -The ovens underneath the flattop grill and stove. -The utensil drawers that were located underneath the kitchen prep table. -The convection ovens. -The reach-in beverage cooler. *Dispose of expired and visibly spoiled foods from one of two reach-in coolers in the kitchen, one of one shared resident refrigerator, one of one dry storage room, and two of two emergency food supply cabinets. *Properly cook unpasteurized eggs prior to serving to one of one sampled resident (34).

Inspectors wroteBased on observation, record review, interview, and hospice service review, the provider failed to develop a collaborative comprehensive care plan that defines hospice care for three of four sampled residents (12, 21, and 49) receiving hospice services.

Inspectors wroteBased on observation, interview, record review, nursing textbook review, and policy review, the provider failed to: *Appropriately check for PEG (percutaneous endoscopic gastrostomy) tube placement prior to administering a liquid medication and enteral nutrition formula for one of one sampled resident (28). *Follow the provider's policy when the pH of the stomach contents was out of range. *Follow the manufacturer's guidelines for refrigerating the cartons of enteral nutrition formula after opening. *Follow professional standards by using cola to unclog one of one resident's (28) PEG tube without obtaining a physician's order.