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The next survey window likely opens around December 2026
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 Mountain View during CMS and state inspections, most recent first.
Non-compliance with F684 occurred when a resident was left without repositioning or continence care for about nine hours overnight due to an unupdated CNA assignment sheet and lack of hand-off communication during a split shift. Another resident, whose care plan required Cares in Pairs because of behavioral and safety concerns, was assisted with toileting by a single CNA, contrary to the documented intervention. In a separate event, a resident who activated a call light for incontinence care waited roughly one and a half to two hours before a CNA changed her brief, after the assigned CNA turned off the call light, returned to another room, and later dismissed reports of the resident hollering, leading another CNA to eventually provide the needed continence care.
The facility failed to adhere to professional standards in medication management, with nurses signing off on controlled substances counts prematurely and a resident self-administering an inhaler without proper assessment. Additionally, an RN documented medication administration before actually administering it, contrary to policy.
The facility failed to properly monitor residents returning from dialysis, as evidenced by inaccurate documentation of post-dialysis vital signs for three residents. A resident with end-stage renal disease reported inconsistencies in monitoring, and records showed discrepancies in vital sign documentation. Another resident also experienced inconsistent vital checks, with records showing outdated data. Staff interviews revealed flaws in the process, with pre-populated data not being updated, contrary to the facility's dialysis management policy.
The facility experienced a medication error rate of 18.75% due to improper administration of diclofenac sodium gel and Flonase nasal spray by staff, contrary to orders and policies. A resident's nebulizer treatment was documented but not administered, and Nystatin powder was given without a physician's order. The DON confirmed these discrepancies.
The facility failed to ensure proper labeling and storage of medications and medical supplies. A resident's Ativan prescription lacked a pharmacy label, preventing verification against the physician's order. Outdated medical supplies were found in storage rooms, and insulin pens for two residents were not labeled or dated correctly. Staff interviews revealed unclear responsibilities for managing outdated supplies, contributing to these deficiencies.
The facility failed to ensure proper cleaning of a whirlpool tub and adequate hand hygiene during medication administration. A CNA did not follow the posted cleaning instructions for the tub, and multiple staff members, including RNs and an LPN, did not perform hand hygiene as required by the facility's policy. Additionally, an RN did not adhere to proper hand hygiene while providing care to a resident with a yeast infection.
The facility failed to ensure care plans for two residents were updated and followed. One resident's care plan lacked specific interventions for manipulative behaviors, while another's inaccurately listed medication, leading to discrepancies in care. Staff interviews confirmed these issues, highlighting a need for accurate and timely care plan updates.
A resident with a history of multiple health issues was administered an antibiotic for a potential UTI without meeting clinical criteria. The facility failed to obtain a urinalysis and did not follow proper documentation and communication protocols. The infection preventionist incorrectly documented that microbiological criteria were met, and the facility's Antibiotic Stewardship Program policy was not followed.
A deficiency was identified when a resident was transported from a dialysis appointment on a facility-operated bus. The bus driver noticed the resident tilted backward in her wheelchair due to a malfunctioning front clamp strap, which failed to secure the wheelchair properly. This incident potentially placed the resident at risk for harm or injury.
A resident inflicted self-harm requiring surgery due to inadequate pain management. Despite having orders for pain medications, there was no documentation of administration, and pain levels were not properly assessed or managed. Staff interviews revealed inconsistencies in following pain management policies.
Failure to Provide Timely Repositioning, Continence Care, and Care Plan–Directed Assistance
Penalty
Summary
Non-compliance with F684 occurred when one resident was not repositioned or provided continence care for approximately nine hours during an overnight shift. Camera footage confirmed that between 8:30 p.m. and 5:41 a.m., the resident did not receive repositioning or incontinence care. The facility’s investigation identified that the staff assignment sheet had not been updated to reflect that two CNAs were splitting the overnight shift, and there was no hand-off communication between the CNAs when one left and the other began the split shift. As a result, the resident’s routine checks and care needs were not carried out during that time period. Additional non-compliance involved another resident whose care plan required "Cares in Pairs," meaning two staff were expected to be present when providing care due to the resident’s history of manipulative behavior, verbal abuse toward staff, recording staff without their knowledge or permission, and making false accusations or statements about staff. Despite this care plan intervention, a CNA assisted the resident with toileting alone, without a second staff member present. The incident was discovered during the investigation of an unrelated event, and there were no adverse consequences reported as a result of this failure. The resident was observed later receiving assistance from two CNAs and reported satisfaction with her care and caregivers. A third incident of non-compliance occurred when a resident who was assigned to a CNA activated her call light for incontinence care and experienced a significant delay before her brief was changed. At the time the call light was activated, the assigned CNA exited another resident’s room, entered the resident’s room, turned off the call light, and then returned to the previous room instead of providing care. Later, the CNA was approached by a family member of another resident and appeared to respond to that request. More than an hour after the initial call light activation, the resident was heard hollering from her room. Another CNA informed the assigned CNA, who dismissed the hollering as the resident wanting her dinner tray removed. A different CNA was then asked to check on the resident and found that the resident had a bowel movement coming out of her brief, with fecal matter on the bedding that appeared to have been present for some time. The resident later confirmed she had soiled her brief and that it took approximately one and a half to two hours before a CNA came to change her. Across these three events, the deficiencies centered on failures to provide timely and appropriate care according to orders, care plans, and residents’ needs and preferences. In the first case, lack of updated assignments and hand-off communication led to missed repositioning and continence care. In the second, a CNA did not follow a clearly documented care plan requiring two staff for care. In the third, the assigned CNA did not respond to a resident’s call light and vocal requests for incontinence care in a timely manner, resulting in prolonged exposure to soiled conditions, even though the resident reported that her care was usually provided promptly and that this was an isolated event.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The report identifies deficiencies in the handling and documentation of controlled medications by nursing staff at the facility. Specifically, it was observed that a registered nurse (RN) and two licensed practical nurses (LPNs) signed the controlled substances count sheet as the offgoing nurse before their shifts had ended and before completing the required medication count with the oncoming nurse. This action was contrary to the facility's policy, which mandates that both the oncoming and offgoing nurses complete and verify the accounting of all controlled medications together at each shift change. Additionally, the report highlights a failure in the assessment and documentation process for a resident self-administering medication. A resident with moderate cognitive impairment and a diagnosis of dementia was observed self-administering an inhaler without prior documented assessments to determine the appropriateness and safety of self-administration. The facility's policy requires an evaluation of the resident's cognitive, physical, and visual ability to self-administer medications, which was not completed until after the resident was observed using the inhaler. Furthermore, the report notes an instance where an RN documented the administration of medications before actually administering them to a resident. This practice was against the facility's medication administration policy, which requires that the administration be recorded immediately after the medication is given. The director of nursing confirmed the expectation that medications should be administered before being documented as given.
Inadequate Monitoring of Post-Dialysis Residents
Penalty
Summary
The facility failed to ensure proper monitoring of residents returning from dialysis treatments, as evidenced by the lack of timely and accurate documentation of post-dialysis vital signs for three residents. Resident 26, who has end-stage renal disease and other significant health conditions, reported inconsistencies in receiving assistance and monitoring upon returning from dialysis. Her electronic medical record showed discrepancies in the dates of recorded vital signs, indicating that the documented post-dialysis vitals were not taken on the actual day of her return from dialysis. Similarly, Resident 33, who also requires regular dialysis, reported that her vital signs were not consistently checked upon her return, and her records showed similar issues with the documentation of vital signs from previous days being used instead of current data. Resident 85, who has multiple health issues including end-stage renal disease and orthostatic hypotension, also had discrepancies in the documentation of his post-dialysis vital signs. Interviews with staff, including a registered nurse and the director of nursing, revealed that the process for recording post-dialysis assessments was flawed, with pre-populated data from previous assessments not being updated with current information. The facility's policy on dialysis management was not adhered to, as it required the review and documentation of post-dialysis information upon the residents' return, which was not consistently done.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The provider failed to ensure proper medication administration, resulting in a medication error rate of 18.75%. Observations revealed that RN G and UMA K did not use the measurement device for diclofenac sodium 1% gel, leading to incorrect dosing for three residents. Additionally, RN I administered Flonase nasal spray in excess of the physician's order for one resident. These actions were contrary to the provider's medication administration policy and the manufacturer's recommendations. Another deficiency was noted when a resident's nebulizer treatment was documented as administered, but the resident reported not receiving it. The nebulizer medicine cup was found with clear liquid, indicating the treatment had not been given. The DON confirmed the resident's statement and acknowledged the discrepancy between the documentation and the actual administration. Furthermore, RN N applied Nystatin powder to a resident without a current physician's order. The resident had a severe yeast infection, and the medication was administered without proper documentation in the electronic medical record. The DON confirmed that all medications should have a current physician's order before administration, which was not adhered to in this case.
Deficiencies in Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and medical supplies, leading to several deficiencies. One resident's prescription for Ativan, an anti-anxiety medication, was not accurately labeled, as the medication bottle lacked a pharmacy label to confirm the resident's identity, dosage information, or instructions for use. This oversight prevented nursing staff from verifying the medication against the physician's order before administration. Additionally, outdated medical supplies, including Ambu bags and hypodermic safety needles, were found in the medication storage rooms, indicating a lapse in the removal of expired items. Further deficiencies were noted with insulin pens for two residents, which were not labeled with pharmacy labels to confirm the identity of the medication, dosage, or usage instructions. The insulin pens were also not dated with the opening date, and staff were unable to locate information on the expiration period after opening. The facility's policy on medication storage did not address the disposal of outdated medical supplies, contributing to the oversight. Interviews with staff revealed a lack of clear responsibility for checking and removing outdated medical supplies, further highlighting the deficiencies in medication and supply management.
Inadequate Infection Control Practices
Penalty
Summary
The provider failed to ensure proper cleaning of the whirlpool (WP) tub by a certified nursing assistant (CNA) who was temporarily assisting with bathing residents. The CNA did not follow the posted cleaning instructions, which required running disinfectant through the aerator holes/jets and allowing the area to stand for at least 10 minutes. Instead, the CNA used a simplified cleaning process that did not meet the facility's standards, as confirmed by the director of nursing (DON). Additionally, there were multiple instances of improper hand hygiene during medication administration by four staff members, including registered nurses (RN), a licensed practical nurse (LPN), and an unlicensed medication aide (UMA). These staff members failed to perform hand hygiene before and after administering medications to residents, and in some cases, did not follow contact precautions for residents on isolation. The facility's hand hygiene policy, which emphasizes handwashing as a primary means to prevent infection spread, was not adhered to during these observations. One resident with a yeast infection was observed receiving personal care from an RN who did not follow proper hand hygiene protocols. The RN washed her hands for only a few seconds between glove changes and did not wash her hands at all before applying clean gloves at one point. This was contrary to the facility's hand hygiene policy, which requires at least 20 seconds of handwashing. The DON confirmed that the expectation was for staff to follow the hand hygiene policy, which was not met in these instances.
Failure to Update and Follow Care Plans for Two Residents
Penalty
Summary
The provider failed to ensure that the care plans for two residents were followed, updated, and revised promptly to reflect their current status and care needs. For Resident 26, interviews with staff revealed that the resident had manipulative behaviors and false accusations, but the care plan lacked specific non-pharmacological interventions to address these behaviors. The social service director acknowledged that the interventions were not listed, and the process to review and update care plans was interdisciplinary. Additionally, the care plan indicated that personal care should be provided with two staff members present, but there was no evidence that this intervention was consistently documented or followed. For Resident 51, the care plan inaccurately reflected that the resident was taking Plavix, an antiplatelet medication, when in fact, the resident was prescribed Eliquis, a blood thinner that requires different monitoring. Interviews with nursing staff confirmed the discrepancy, and the director of nursing noted that medications were not typically specified on care plans due to potential changes. However, the expectation was for care plans to be updated as the resident's care and needs changed. The facility's care plan policy emphasized the importance of individualized, resident-centered care planning and the need for care plans to be updated to reflect current care needs.
Failure to Ensure Clinical Criteria for Antibiotic Use in Suspected UTI
Penalty
Summary
The provider failed to ensure that a resident who received an antibiotic for a potential urinary tract infection (UTI) met the clinical criteria for its use. The resident, who had a history of diabetes, peripheral vascular disease, depression, insomnia, and anorexia, was reported to have mood changes, low appetite, and dysuria. A medical provider ordered a urinalysis (UA) and started the resident on cefdinir, an antibiotic, for a potential UTI. However, the UA was not obtained, and the antibiotic was administered without confirming the UTI diagnosis through appropriate clinical assessment or microbiological evidence. Interviews with facility staff revealed that the expected documentation and communication protocols were not followed. A Suspected UTI SBAR form, which should have been completed by the nurse, was not found at the second-floor nurses' station. Additionally, there was no documentation explaining why the UA was not obtained, whether further attempts were made to collect the urine sample, or if the medical provider was informed of the inability to obtain the UA. The infection preventionist incorrectly documented that microbiological criteria were met, despite the lack of a UA. The facility's Antibiotic Stewardship Program policy emphasizes the importance of appropriate antibiotic use, which was not adhered to in this case.
Deficiency in Wheelchair Securement on Facility Bus
Penalty
Summary
A deficiency was identified when a resident was being transported from a dialysis appointment to the facility on one of the provider's buses. During the transport, the bus driver noticed through the rear-view mirror that the resident was tilted backward in her wheelchair. Upon further assessment, it was discovered that one of the front clamp straps used to secure the wheelchair was extended, indicating a malfunction. The tie-down system, which is designed to automatically tighten when the strap loosens due to normal bus movements, failed to function as intended. This malfunction in the tie-down system potentially placed the resident at risk for harm or injury. The incident highlights a failure in ensuring that the wheelchair was safely secured during transport, which is a critical aspect of resident safety. The deficiency was identified through a review of the facility-reported incidents, interviews, and record and policy reviews conducted by the South Dakota Department of Health.
Inadequate Pain Management Leading to Resident Self-Harm
Penalty
Summary
The provider failed to ensure adequate pain management for a resident who inflicted self-harm that required surgical treatment. The resident, who was cognitively intact and had no signs of depression, inflicted a stab wound to his abdomen and was transferred to the hospital for surgery. The incident revealed non-compliance in the pain management process, including inadequate pain documentation, failure to document the administration of pain medication, and incomplete pain assessments. The resident had multiple diagnoses, including rheumatoid arthritis and other conditions that could cause pain. Despite having physician orders for various pain medications, there was no documentation that Tylenol, which was ordered as needed for pain, had been administered. The resident's pain levels were documented as high on several occasions, but there was no evidence that any interventions were provided to relieve his pain. Interviews with staff revealed inconsistencies in the pain management process. The admitting nurse failed to enter standing orders for pain medication into the electronic medical record, and there was a lack of documentation of pain assessments and interventions. The provider's policies on pain management and following physician orders were not adequately followed, contributing to the resident's unmanaged pain and subsequent self-harm.
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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 Rapid City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Saint Cloud | 1.1 mi | — | 6 | 0 |
| Avantara Arrowhead | 1.5 mi | — | 20 | 0 |
| Clarkson Health Care | 1.8 mi | — | 1 | 0 |
| Fountain Springs Healthcare | 1.9 mi | — | 11 | 0 |
| Avantara North | 1.9 mi | — | 2 | 0 |
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