Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avantara Huron during CMS and state inspections, most recent first.
Two residents experienced preventable safety incidents due to inadequate supervision and failure to follow care plans. A resident with severe cognitive impairment and documented high elopement risk exited through the front door unnoticed after following a staff member, while the receptionist’s view was obstructed by multiple visitors entering, allowing the resident to reach the parking lot before being brought back inside. In a separate event, a resident at high fall risk, whose care plan required one-person assist with a gait belt for transfers, was transferred by a CNA from a bath chair to a wheelchair without a gait belt; the resident could not continue standing and was eased to the floor, resulting in a skin tear to the eyebrow and a large bruise on the upper arm, despite stable vitals and baseline ROM and neuro status.
Two incidents of neglect occurred when CNAs failed to follow care plans. One resident was left in the same clothes and incontinent overnight, while another fell during an improper transfer. Both incidents involved miscommunication and failure to adhere to care plans, resulting in neglect.
The facility failed to maintain sanitary conditions in the kitchen, with improper temperature monitoring and food storage practices. Observations revealed temperature discrepancies in the walk-in freezer and fridge, with no corrective actions documented. Interviews with dietary staff highlighted a lack of knowledge and documentation regarding temperature checks and food disposal. The facility's policies on freezer defrosting, food storage, and temperature recording were not followed, leading to unsanitary conditions.
The facility failed to maintain an ice machine in a sanitary manner, with pink slime and rust observed. Two residents with MRSA were not placed on contact precautions, contrary to policy. An LPN did not follow proper infection control practices during medication administration for a resident on COVID-19 precautions. Staff interviews revealed inadequate cleaning procedures and lack of recent education on infection control.
The facility failed to provide baseline care plan summaries to fourteen residents within 48 hours of admission. Staff interviews revealed that the social services designee did not review or provide summaries due to insufficient training, and the RN did not document the reviews in the EMR. The facility's policy mandates completion of baseline care plans within 48 hours, which was not followed.
A facility failed to provide bed-hold notices to a resident and their representative during two hospital transfers. The resident's records showed three hospital transfers, but only the first included a bed-hold notification. An interview confirmed the lack of documentation for the latter transfers. The facility's policy requires informing residents or their representatives of the bed-hold option at admission and upon each transfer.
A resident's care plan was not updated to include contact precautions after a MRSA diagnosis, and lacked interventions for her behavior of barricading herself in her husband's room. The care plan also did not address the use of family as an intervention, despite their involvement. Additionally, Prevalon boots were used but not listed as an intervention for her wounds.
A resident with a history of surgery and multiple diagnoses reported pain, but the facility failed to provide adequate pain management. Despite having an order for Tramadol, the medication was unavailable due to a missing prescription, and the resident's care plan interventions were not effectively implemented. Interviews revealed a lack of follow-up with the physician and inconsistencies in entering standing orders into the EMR.
A resident requiring dialysis treatment was not properly monitored upon returning from dialysis sessions. The facility failed to consistently document the resident's vital signs post-dialysis, with some entries using outdated data. Interviews revealed that the process for obtaining and documenting these vital signs was not consistently followed, leading to incomplete records.
The facility failed to maintain cleanliness in the kitchen, with range hood vents covered in grease, an ice machine with hard water scale, and stained ceiling tiles. The range hood was not on the weekly cleaning schedule, and maintenance had not cleaned the vents in June. The ice machine was due for replacement, and the ceiling stains were attributed to condensation. The cleaning tasks were marked as completed in previous months, but the provider's policy required compliance with cleaning schedules.
Failure to Prevent Elopement and Injury Due to Inadequate Supervision and Noncompliance With Transfer Protocols
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents. In the first incident, a resident with severely impaired cognition, as evidenced by Brief Interview for Mental Status (BIMS) scores of three and zero on prior assessments, had been identified as a high elopement risk with elopement risk assessment scores of five on two separate dates. Her care plan prior to the incident included non-pharmaceutical interventions for wandering, such as cueing, reorienting, supervising, use of an animatronic dog, conversation, walking with her, inviting her to activities, encouraging rest, and providing less stimulation when she was anxious, delusional, or wandering. Despite these identified risks and interventions, the resident was able to exit the building through the front door without staff knowledge. On the date of the elopement, the resident was ambulating with a walker throughout the facility and followed a staff member who was leaving the property out the front door. She exited the building at 2:48 p.m. and was seen outside in the parking lot by the front door at 2:50 p.m., at which time she was escorted back into the facility. The DON later stated that during this elopement, a staff member let in five family members through the front door, which crowded the receptionist’s direct line of sight and prevented the receptionist from seeing the resident use her walker to leave the facility. The DON also stated that residents were mobile and deemed elopement risks, and that if they got outside, it was considered an elopement based on facility policy. The facility’s elopement policy required the facility to take steps to keep residents safe and assess residents to identify those at risk for elopement. The second incident involved a resident with a care plan indicating she was to be transferred with one-person assistance using a walker and a gait belt, and who had been assessed as being at high risk for falls. On the date of the fall, a CNA assisted this resident from a bath chair to her wheelchair without using a gait belt, contrary to the resident’s care plan and the facility’s Transfer and Gait Belt Use policy. During the transfer, the resident was unable to continue standing, and the CNA eased her to the floor, where she was found lying on her right side at the foot of her bed. Assessment by an LPN revealed a one-centimeter skin tear to the right eyebrow, which was closed with a steri-strip, and a light blue bruise measuring ten centimeters by three centimeters on the right upper arm. The resident’s range of motion, neurological assessments, and vital signs were within normal limits, and she reported pain at a level of three on a zero-to-ten scale. The CNA later confirmed he knew a gait belt was required for this resident but did not use one and was unsure why.
Neglect Due to Failure to Follow Care Plans
Penalty
Summary
The provider failed to protect residents from neglect in two separate incidents. In the first incident, a CNA did not provide nighttime care for a resident who was found the next morning in the same clothes from the previous day and incontinent of bowel. The resident had been recently readmitted from the hospital with a history of red and sore buttocks. Despite the resident's care plan being updated upon her return, the CNA and the charge nurse on duty did not ensure the care plan was followed, resulting in neglect. In the second incident, a CNA did not follow the care plan for a resident with moderate cognitive impairment during a transfer. The resident was supposed to be transferred using a stand-up lift during the evening shift, but the CNA attempted a stand and pivot transfer, leading to the resident's fall. The CNA misread the care plan, which clearly indicated the need for a stand-up lift during the evening and night shifts. Both incidents highlight a failure to adhere to established care plans, resulting in neglect. The residents involved had specific care needs that were not met, leading to situations that could have been avoided if the care plans were properly followed. The facility's policies on neglect emphasize the importance of providing necessary and adequate care to avoid harm, which was not achieved in these cases.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The provider failed to maintain clean and sanitary conditions in the kitchen where residents' food was stored and prepared. Observations revealed that the walk-in freezer had temperatures recorded outside the adequate range, with no documented actions taken to address these discrepancies. There was ice build-up around the door, the metal lining was separated, and frost was present on the cooling unit. The three-door fridge unit also had temperature variances without documented corrective actions. Additionally, there were issues with food storage, such as undated chicken nuggets, freezer-burned chicken, and improperly stored meat. Interviews with the dietary manager and aides highlighted a lack of knowledge and documentation regarding temperature checks and food disposal. The dietary manager admitted to not documenting actions taken when thermometers did not match and was unaware of the proper disposal process for food based on package dates. The administrator was aware of the ice build-up but not of the failure to discard partially thawed food. The facility's policies on freezer defrosting, food storage, and temperature recording were not adhered to, contributing to the unsanitary conditions. The provider's policies outlined specific guidelines for freezer defrosting, food storage, and temperature monitoring, which were not followed. Freezers were supposed to be frost-free, and food should not show signs of defrosting or refreezing. The facility's failure to adhere to these policies resulted in unsanitary conditions in the kitchen, with improperly stored and potentially unsafe food items. The lack of documentation and adherence to procedures by the dietary staff further exacerbated the issue.
Infection Control Deficiencies in Ice Machine Maintenance and Resident Precautions
Penalty
Summary
The provider failed to maintain an ice machine in a clean and sanitary manner, as observed in the therapy room. The ice machine had pink slime on the water/ice spout, rusted metal bars over the water tray, and a white, flaky residue on the underside of the machine. Interviews with staff revealed that housekeepers only cleaned the outside of the machine, while maintenance staff were responsible for internal cleaning. However, the maintenance director admitted to using inappropriate cleaning chemicals and not following the manufacturer's instructions for cleaning and sanitizing the machine. The provider also failed to place two residents on contact precautions despite their diagnoses with multi-drug resistant organism (MDRO) infections. One resident had Methicillin-resistant Staphylococcus aureus (MRSA) in her left ankle and was receiving intravenous antibiotics, yet was only on enhanced barrier precautions. Another resident, diagnosed with MRSA in her right ankle wound, was also not advanced to contact precautions. Interviews with nursing staff confirmed the oversight in precautionary measures, which contradicted the facility's MRSA policy. Additionally, infection control practices were not maintained during medication administration for a resident on COVID-19 precautions. An LPN failed to wipe off a nasal spray applicator after use and did not follow proper procedures for handling the nasal spray outside the precaution room. Interviews with staff revealed a lack of recent education on infection control practices, particularly regarding nasal spray administration in precaution rooms. The facility's policies did not address these specific infection control practices.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The provider failed to ensure that fourteen out of twenty-nine residents received a summary of their baseline care plan within 48 hours of admission. The records for residents 10, 23, 46, 49, 53, 55, 64, 65, 67, 70, 224, 274, 375, and 424 showed no documentation that a baseline care plan summary had been reviewed with the residents or their representatives. Additionally, the baseline care plan for resident 424 was not signed as completed until a later date, indicating a delay in the process. Interviews with staff revealed gaps in the implementation of baseline care plans. The social services designee admitted to not reviewing or providing a summary of the baseline care plan to residents or their representatives, citing insufficient training since assuming the position. The clinical care coordinator RN also acknowledged not documenting the review of the baseline care plan in the residents' electronic medical records (EMR). The facility's policy requires that a baseline care plan be started on the first day of admission and completed within 48 hours, which was not adhered to in these cases.
Failure to Provide Bed-Hold Notice During Hospital Transfers
Penalty
Summary
The provider failed to provide bed-hold notices to a resident and their representative during two out of three hospital transfers. The resident's electronic medical record indicated transfers to the hospital on three occasions. While the representative was notified of the bed-hold policy during the first transfer, there was no documentation of such notification for the subsequent transfers. An interview with the social service designee confirmed the absence of documentation for the latter two transfers. The facility's Bed Reserve Policy and Bed-Hold and Return Agreement require that residents or their representatives be informed of the bed-hold policy at admission and upon each transfer, allowing them to request a bed-hold by paying a daily rate.
Failure to Update Resident Care Plan for MRSA and Behavioral Interventions
Penalty
Summary
The provider failed to ensure the timely review and revision of a resident's care plan, specifically for a resident who was admitted with multiple wounds and later diagnosed with MRSA. The resident's care plan initially included Enhanced Barrier Precautions (EBP) due to her wounds, but after the MRSA diagnosis, the care plan was not updated to include contact precautions. Additionally, the care plan did not list Prevalon boots as an intervention for her wounds, despite their use being observed. The care plan also lacked focus areas, goals, or interventions addressing possible complications related to the resident's diagnosis of rhabdomyolysis. Furthermore, the resident had a history of barricading herself in her husband's room, which was noted in her nurse progress notes. However, the care plan did not include interventions for this behavior, nor did it address the use of family as an intervention, despite family being called multiple times to help calm her behaviors. The facility's policy requires individualized, resident-centered care planning to be maintained throughout the resident's stay, with updates reflecting current care needs as changes occur, which was not adhered to in this case.
Inadequate Pain Management for Resident
Penalty
Summary
The provider failed to ensure adequate pain management for a resident who expressed experiencing pain. The resident, who had a history of right-hand surgery, back pain from a fall, and multiple diagnoses including peripheral vascular disease and type 2 diabetes, reported pain on the left side of her body. Despite having an active physician order for Tramadol, a pain medication, the medication was not available on the medication cart, and the resident was informed by an LPN that no pain medication was available. The resident's care plan included interventions for pain management, such as providing analgesics as ordered and notifying the physician if pain relief was inadequate, but these were not effectively implemented. The deficiency was further highlighted by the lack of a written prescription for Tramadol being sent to the pharmacy, which delayed the medication's availability. Interviews with the DON and CCC confirmed that the pharmacy had not received the necessary prescription, and the CCC acknowledged that the provider should have followed up with the physician. Additionally, standing orders for pain control were not consistently entered into the resident's EMR upon admission. The facility's pain management policy outlined procedures for identifying and managing pain, but these were not adequately followed, resulting in the resident's pain not being addressed in a timely manner.
Failure to Monitor and Document Post-Dialysis Vital Signs
Penalty
Summary
The provider failed to ensure proper monitoring of a resident who required dialysis treatment, specifically in documenting vital signs post-dialysis. The resident, who had a dialysis port in his chest and received dialysis three times a week, had a care plan that required significant changes in pulse, respirations, and blood pressure to be reported immediately. However, the resident's electronic medical record showed discrepancies in the documentation of post-dialysis vital signs, with some entries using outdated data from previous dates instead of current readings. Interviews with the registered nurse and the director of nursing revealed that the process for documenting post-dialysis vital signs was not consistently followed. The nurse acknowledged that the vital signs should ideally be taken and documented each time the resident returned from dialysis, but this did not always occur. The director of nursing confirmed that the expectation was for vital signs to be obtained and documented each time, but this was not consistently done, leading to incomplete and inaccurate records for the resident's post-dialysis condition.
Kitchen Cleanliness Deficiency
Penalty
Summary
The provider failed to maintain cleanliness in the kitchen, specifically regarding the range hood vents, ice machine, and ceiling tiles. During an observation, the range hood vents were found to be covered with a greasy film and lint, while the ice machine had a layer of hard water scale build-up on its sides and embedded deposits between the cooling fan fins. Additionally, ceiling tiles above the refrigerator had dark water stains. Interviews revealed that the range hood was cleaned by a contracted service, but the dietary aide was unsure of the last cleaning date, and the range hood was not included in the weekly cleaning schedule. The dietary manager confirmed the lack of a cleaning schedule for the range hood and noted that maintenance was responsible for cleaning the vents, which had not been done recently. The maintenance director used a computer program to track maintenance tasks and stated that the range hood and vents were to be cleaned monthly, but the vents had not been cleaned in June. The ice machine, which had been moved from another area, was cleaned when the kitchen floor was replaced in May, but it was due for replacement. The maintenance director also acknowledged the need to replace the stained ceiling tiles, attributing the stains to condensation from the air conditioning duct. A review of the kitchen exhaust fan log showed that cleaning tasks were marked as completed from January to May 2024, and the provider's cleaning policy required the Food and Nutrition Services staff to maintain sanitation through compliance with written cleaning schedules.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Huron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie View Healthcare Center | 20.8 mi | — | 2 | 0 |
| Weskota Manor Inc | 24.9 mi | — | 3 | 0 |
| Good Samaritan Society De Smet | 33.7 mi | — | 3 | 0 |
| Avantara Redfield | 38.6 mi | — | 9 | 0 |
| Eastern Star Home Of South Dakota, Inc | 38.6 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.