Avantara Redfield

Inspectors wroteBased on interview, resident council meeting, resident council meeting minutes review, grievance forms review, and policy review, the provider failed to ensure that grievances regarding the food quality of residents' meals were addressed, and documentation reflecting the staff's efforts to resolve those grievances was communicated to the residents and approved as effective resolutions for:*Nine of nine residents (13, 18, 19, 22, 24, 36, 40, 50, and 51) who individually reported concerns in grievance records reviewed from July 2025 through January 2026.*Five of five residents (12, 19, 25, 32, and 44) who attended the resident council meeting on 1/26/26.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to develop a person-centered baseline care plan that included the minimum healthcare information necessary to provide care for four of five newly admitted residents (8, 18, 32, and 33) and failed to ensure the resident's baseline care plan was reviewed with the resident or resident representative within 48 hours of admission for three of five newly admitted residents (18, 32, and 33).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure staff members followed quality of care practices and professional standards that ensured:*A Roho cushion's (air filled cushion designed for high-level pressure ulcer prevention and treatment) were used and maintained according to manufacturer's instructions for one of one sampled resident (5) with a pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) to her buttocks and upper thighs.*Specialized compression garments had complete physician's orders for use and were applied according to the manufacturer's instructions for one of one sampled resident (5) with lymphedema (tissue swelling caused by blocked lymph node fluid drainage) who used Circaids (adjustable compression garments designed to treat lymphedema, venous insufficiency, and edema).*A urine sample was [...]

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to monitor and document the temperatures for one of one commercial dishwashing machine according to the provider's policy to ensure it reached the minimum rinse cycle temperature of 180 degrees for sanitization of dishes and equipment used to prepare and serve residents' meals after every meal service.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the staff followed standard infection control practices regarding:*Hand hygiene (handwashing or hand sanitizer use) and gloves used by one of one certified medication aide (CMA) (H), and one of one licensed practical nurse (LPN) (G) while providing personal cares for resident 5.*Hand hygiene and use of personal protective equipment (PPE) (such as a gown, gloves, and mask) by one of one certified nursing assistant (CNA) (S) observed while delivering meal trays to four of four sampled residents (10, 14, 20, and 22) with COVID-19 (a contagious disease that can spread quickly) and on enhanced droplet precautions (which need and a N95 mask (a mask that filters 95 percent of airborne particles), gown, gloves, and eye protection to be worn when entering those rooms) according to the provider's policy.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure two of two sampled resident's (25 and 43) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment was accurately coded for the Pre-admission Screening and Resident Review (PASRR).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow food safety standard pratices to ensure resident food temperatures were monitored and recorded according to the provider's policy for all meals prepared and served in one of one kitchen.

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 safety for one of one sampled resident (1) who was served a food item she had a documented food allergy to. The failure of serving the resident a food item that was identified as a food allergy resulted in the resident's allergic reaction symptoms and need for evaluation and treatment at the emergency department. 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 document review, the provider failed to ensure food items were appropriately labeled, stored, handled, prepared, and served to residents in a safe and sanitary manner in one of one kitchen and one of one dining rooms for the following: *One of one kitchen was not maintained in a safe and sanitary manner. *One of one commercial refrigerator contained beverage items that were not labeled, dated, or discarded by the use-by date. *Unsafe meat thawing practices. *Inappropriate glove use and hand hygiene by four of four observed dietary staff (dietary manager C, cook D, cook E, and dietary aide (DA) I) while preparing and serving residents' food. *Inappropriate glove use and hand hygiene by four of four observed staff (certified nursing assistant (CNA) K, CNA L, CNA N, and restorative aide (RA) J) while assisting residents in the dining room.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to maintain a clean and homelike environment for 5 of 49 sampled residents (6, 7, 13, 16, and 19) and for the residents who ate their meals in the main dining room.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure that essential dietary department kitchen equipment was in safe working condition including: *Five of the eight stove-top burners on the commercial gas stove that did not ignite. *Two of the two ovens in the commercial gas stove that were not in working condition. *One of one flattop grill that leaked oil down the side of the equipment and onto the floor beneath. *The two-compartment food preparation sink leaked and was not used to prepare food. *The air conditioning unit in the kitchen ceiling had condensation tubing attached to the faucet and drained into the handwashing sink.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *The foam filter was replaced on one of one sampled resident's (34) oxygen concentrator machine. *One of one sampled resident (34) had current physician's orders to receive oxygen therapy. *Facility policy had been followed regarding documenting oxygen tubing and foam filter replacement in one of one sampled resident's (34) electronic medical record (EMR).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, policy review, and interview the provider failed to ensure the safety for one of one sampled resident (1) who staff let out of the building in the early morning hours. Resident left the grounds and his wheelchair got stuck on the railroad tracks, and was unable to get himself free. The county sheriff found him and called the provider to let them know that he was gone. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident.

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 safety for one of one sampled resident (2) identified at risk for elopement, had eloped (left the facility without staff knowledge) and was outside the building approximately 2 hours and 4 minutes when an activity door was left unalarmed. Failure of staff to ensure the door alarm was rearmed resulted in the resident's elopement and put him at risk for physical injury or serious harm. Specifically, the provider failed to monitor/revise interventions after elopement to ensure resident safety.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure wound care treatments were completed per physician orders and documented for one of one resident (2).

Inspectors wroteBased on observation, interview and a cleaning checklist for housekeepers the provided failed to ensure a clean and homelike environment that included the following: *A handwashing sink in the dining room that had noticeable water damage and one of the doors were hanging off the hinge. *A cracked half-wall located in the resident's shower room. *A resident's door opening only halfway and leaving grooves in the floor. *Paint on a heating unit in a resident's room is peeling away. *A wall heating unit in the dining room was that pulling away from the wall. *Spider webs around a non-exit door. *Multiple non-used screws in the wall. *Wallpaper in multiple places throughout the facility was bubbling and peeling away from the wall. 1. Observation on 8/29/23 8:32 a.m. in the main dining room revealed: *A handwashing sink was located next to the entrance to the kitchen. [...]

Inspectors wroteBased on observation, interview, record review, email communication review, and policy review, the provider failed to ensure: *A functional whirlpool tub was available to all residents who preferred a tub bath. *Scheduled showers were offered and given to 16 of 40 sampled residents (3, 5, 6, 10, 12, 15, 17, 20, 23, 24, 25, 30, 32, 33, 38, and 40).