Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Pierre during CMS and state inspections, most recent first.
A resident with multiple chronic conditions reported acute pain and lack of pain medication to a nurse consultant. The night shift RN did not notify the on-call physician for pain medication orders, citing abnormal labs, and only offered non-pharmacological interventions, which were refused. No documentation of the pain complaint or interventions was made, and the process for contacting the on-call physician was not clearly posted or included in orientation, resulting in a deficiency in pain management.
A resident with frequent loose stools due to lactulose for hepatic encephalopathy was not provided personal hygiene after an incontinent episode before being sent to the ER. The RN on duty, aware of the resident's condition, did not clean the resident prior to ambulance transport, resulting in the resident arriving at the hospital in a soiled state and feeling distressed by the situation.
A resident with hemiparesis, diabetes, and impaired mobility was admitted at high risk for pressure ulcers, but physician-ordered prevention interventions such as an air mattress and heel protection were not implemented or documented. The care plan did not include these measures, and the resident developed a new pressure ulcer before any prevention equipment was provided. Staff confirmed that required interventions were not in place prior to the ulcer's development.
Fifty residents who signed arbitration agreements at admission were not given the required 30-day period to rescind the agreement, as the document only allowed 10 days. A resident interviewed was unaware of the arbitration agreement details, and the administrator confirmed all affected residents received the same version. The facility's policy stated a 30-day rescission period, but the agreement provided to residents did not match this policy.
Three residents experienced cold and uncomfortable room temperatures, as confirmed by observations and temperature readings below the facility's required range. Residents reported having no control over their room temperatures and used extra blankets or walked the halls to stay warm. The facility's boiler system and leaking windows contributed to the issue, and only maintenance staff could adjust locked thermostats, which were not located in resident rooms.
Four residents did not have their care plans accurately updated or interventions implemented as required, including missing or improperly placed fall mats and call lights, lack of documented pressure ulcer prevention measures, failure to provide a required positioning alarm, and omission of physician-ordered lymphedema wraps from the care plan. These deficiencies were identified through observations, interviews, and record reviews.
Staff did not follow enhanced barrier precautions when providing direct care to a resident with a catheter, MDRO, and a pressure injury, as gloves were used but gowns were not worn. In the whirlpool tub room, CNAs failed to use the correct disinfectant and cleaning procedure as outlined by the manufacturer's instructions, and cleaning products were not properly labeled or dated. The laundry room had uncleanable surfaces due to damaged flooring and walls, improper airflow from a fan, and lift slings stored on the floor, with cleaning logs showing incomplete maintenance.
A resident was allowed to self-administer medications, including a nebulizer treatment and nasal spray, in their room without staff supervision or a physician's order, despite an evaluation indicating the resident was not able to self-administer medications. Staff left medications at the bedside, and the DON confirmed the absence of required authorization and assessment per facility policy.
A resident with a history of burns from smoking and mental health conditions was not assessed for smoking risks as required by facility policy. The care plan called for staff supervision and safety measures during smoking, but quarterly and readmission smoking risk assessments were missed. Staff interviews revealed confusion about who was responsible for completing these assessments, and the EMR system did not prompt for them, resulting in a failure to ensure adequate supervision and accident prevention.
Failure to Notify Physician and Document Acute Pain Complaint
Penalty
Summary
A resident with multiple significant diagnoses, including cirrhosis of the liver, diabetes mellitus type II, cardiomyopathy, unspecified convulsions, difficulty with walking, and glaucoma, reported acute stomach pain to a senior regional nurse consultant. The resident also expressed concerns that two night nurses were not providing water or pain medication. At the time, the resident did not have any physician orders for pain medication, and his care plan included interventions for pain management, such as asking for medication and having pain levels reviewed every shift. On the night in question, the registered nurse (RN) on duty was aware of the resident's pain complaint but did not notify the on-call physician to obtain an order for pain medication. The RN cited concerns about the resident's abnormal lab values, specifically elevated liver enzymes and low platelets, as reasons for not administering acetaminophen or ibuprofen. Instead, the RN offered non-pharmacological interventions, such as repositioning, which the resident refused. The RN did not document the resident's pain complaint, the interventions offered, or the resident's refusals in the progress notes. The RN reported the situation to the oncoming nurse but did not take further action to address the resident's pain during her shift. Interviews with facility staff revealed that the process for contacting the on-call physician was not clearly posted or included in the nurse orientation checklist at the time of the incident. The director of nursing expected that nurses would notify the on-call physician if a resident without pain medication orders complained of pain, but this expectation was not met. The lack of timely physician notification and absence of documentation regarding the resident's pain and interventions led to the deficiency in providing safe and appropriate pain management.
Failure to Provide Personal Hygiene Prior to ER Transfer
Penalty
Summary
A resident who was cognitively intact and recently admitted to the facility experienced an episode of incontinence with loose stool prior to being transported to the emergency room (ER) for evaluation. The resident had a history of frequent loose stools related to lactulose use for hepatic encephalopathy and was on a strict fluid restriction. On the evening of the incident, after a total bed change was completed following an earlier incontinent episode, the resident again became incontinent of loose stool just before the arrival of the ambulance team. The registered nurse (RN) on duty was informed by the paramedic about the resident's condition. Despite this, the RN did not provide personal hygiene or clean the resident before transport, citing concern about making the paramedics wait. The resident was subsequently transported to the ER in a soiled state. Upon arrival at the hospital, staff there expressed their dissatisfaction with the resident's condition, and the resident reported feeling bad about the situation. The resident also stated that staff had time to change him before he left for the hospital and recalled hearing the paramedic inform the RN of his incontinence. The facility's policies on abuse, neglect, and resident dignity require that residents be provided necessary care to avoid harm or pain, including personal hygiene after incontinence. The failure to provide personal hygiene to the resident prior to ER transfer, despite awareness of his needs and the opportunity to address them, constituted neglect and a violation of the resident's right to dignity and proper care.
Failure to Implement Pressure Ulcer Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to identify and implement pressure ulcer prevention interventions for a resident who was at high risk for skin breakdown and dependent on staff for activities of daily living. Upon admission, the resident was assessed as high risk for developing pressure ulcers, with a Braden score dropping from 18 to 6 within four days, but there was no documentation that physician-ordered interventions such as the use of an air mattress, floating heels, or pressure redistributing cushions were initiated. The resident's care plan did not reflect these interventions, and there was no evidence that the pressure ulcer prevention and treatment orders were implemented upon admission. Observations revealed that the resident was using blue padded pressure-reducing boots and a compression stocking, but these were only provided after a pressure ulcer was identified on the right heel. The resident did not have an air mattress on the bed as ordered, and staff interviews confirmed that the required interventions were not in place prior to the development of the pressure ulcer. The wound care nurse and DON both acknowledged that the resident developed a new pressure ulcer after admission and that the prevention measures were not included in the care plan or implemented as required. The facility's policy required a plan of care for residents at risk for skin breakdown and immediate implementation of individualized prevention programs based on assessment. However, the lack of documentation and failure to follow physician orders and facility policy led to the development of a facility-acquired pressure ulcer in a resident with significant risk factors, including hemiparesis, diabetes, and impaired mobility.
Failure to Provide Required 30-Day Rescission Period for Arbitration Agreements
Penalty
Summary
The provider failed to ensure that 50 out of 55 residents who signed an Arbitration Agreement upon admission were explicitly granted the right to rescind the agreement within 30 calendar days, as required. Observation and interview with a cognitively intact resident revealed she was unaware of the specifics of the Voluntary Agreement for Arbitration she had signed and did not recall signing it. Review of her admission documents confirmed the inclusion of arbitration information, but the agreement itself only allowed a 10-day rescission period, contrary to regulatory requirements. Further review of the provider's undated Voluntary Agreement for Arbitration and policy showed a discrepancy: while the policy stated a 30-day rescission period, the actual agreement given to residents only allowed 10 days. The administrator confirmed that all residents admitted after the 2019 implementation had signed the same agreement and was unsure why the agreement did not reflect the 30-day period. The social services director, responsible for reviewing the agreement with residents, was unavailable for interview during the survey.
Failure to Maintain Adequate Room Temperatures for Residents
Penalty
Summary
The facility failed to maintain adequate room temperatures for three residents who reported their rooms were cold and uncomfortable. Observations confirmed that the rooms of these residents felt colder than other areas of the facility, and residents were observed using extra blankets, wearing additional clothing, and placing items along windows to block drafts. Residents reported having no control over their room temperatures and described ongoing discomfort, with one resident stating she had to stay in bed under blankets to keep warm, and another walking the halls to warm up. Temperature measurements taken in one resident's room showed readings below the facility's required range, with wall temperatures as low as 65.3°F, despite the facility's policy stating that resident room temperatures should be maintained between 71 and 81°F. The maintenance director acknowledged the difficulty in maintaining consistent temperatures due to the building's boiler system and leaking windows, and confirmed that thermostats were not present in resident rooms and were locked to prevent resident or staff adjustment. Only maintenance staff could adjust the thermostats, which were set between 70 and 72°F, and temperature checks were performed by averaging readings from a few rooms. Interviews with staff and review of facility policies confirmed that residents did not have the ability to control their own room temperatures and that complaints about cold rooms had been raised previously, including at a resident council meeting. The facility's homelike environment policy emphasized the importance of comfortable temperatures, but the observed conditions and resident reports demonstrated that the facility did not ensure a safe, comfortable, and homelike environment as required.
Failure to Implement and Update Resident Care Plans and Interventions
Penalty
Summary
The facility failed to ensure that care plans accurately reflected the current needs of four residents and that interventions listed in the care plans were implemented as directed. For one resident with a history of falls and severe cognitive impairment, observations revealed that the fall mat was not properly placed and the call light was not within reach, contrary to the care plan instructions. The resident's care plan specifically required the bed to be in a low position, a fall mat to be placed next to the bed, and the call light to be accessible, but these interventions were not consistently provided. Another resident, who was admitted with hemiparesis and later developed a pressure ulcer on the right heel, did not have appropriate pressure ulcer prevention interventions included in the care plan. Although physician orders and staff interviews indicated the need for an air mattress, pressure-reducing boots, and regular repositioning, these interventions were not documented in the care plan prior to the development of the pressure ulcer. The resident was only provided with pressure-reducing boots after the ulcer was identified, and there was no documentation of air mattress use or trial. A third resident, who required a positioning alarm (tabs alarm) as per physician orders and care plan, was repeatedly observed without the alarm in place while in bed or in a wheelchair. Staff interviews confirmed that the use of the tabs alarm was not consistently communicated or implemented. Additionally, a fourth resident with lymphedema received daily Ace wrap treatments from therapy staff as ordered by a physician, but this intervention was not included in the resident's care plan. Nursing staff were not trained on the use of the wraps, and the care plan did not address this aspect of care, despite expectations from facility leadership that all treatments should be reflected in the care plan.
Infection Control Deficiencies in Resident Care, Whirlpool Cleaning, and Laundry Room Maintenance
Penalty
Summary
Staff failed to follow appropriate infection control practices in several areas of the facility. Two certified nursing assistants (CNAs) did not use gowns while providing direct care, including personal hygiene and changing undergarments, to a resident who had a catheter, a multidrug-resistant organism (MDRO), and a pressure injury. The signage on the resident's door and the care plan both indicated that enhanced barrier precautions (EBP), including the use of gloves and gowns, were required during high-contact care activities. However, the CNAs only wore gloves and did not believe gowns were necessary unless they were emptying the catheter, which was inconsistent with facility policy and the infection preventionist's expectations. In the whirlpool (WP) tub room, two CNAs used different disinfectant products to clean the tub between resident uses, but neither followed the manufacturer's instructions. The spray bottles used for cleaning were not dated, and there was no indication of the required wet contact time for effective sanitization. The manufacturer's manual specified the use of a particular disinfectant, a long-handled brush for cleaning, and a specific procedure, none of which were followed. The director of nursing confirmed that the correct process was not used and that the required disinfectant was not available. The laundry room was also found to have multiple infection control deficiencies. There were uncleanable surfaces due to cracked or missing tiles and peeling paint, both in the main laundry area and the clean linen room. A wall-mounted fan was positioned to blow air from the soiled to the clean area, and mechanical lift slings were stored in a way that allowed them to touch the floor and accumulate dust. Cleaning logs for the laundry room were incomplete or missing for several days, and the infection preventionist confirmed that the areas were not being maintained or cleaned as expected.
Failure to Ensure Safe and Authorized Self-Administration of Medications
Penalty
Summary
A resident was observed self-administering medications, including a nebulizer treatment, Tums, and Fluticasone Propionate nasal spray, in his room without staff supervision. The resident stated he was able to independently manage his medications, and nurses left medications on his bedside table for him to take. Observations confirmed that no staff were present during the administration of the nebulizer treatment, and medications were accessible to the resident in his room. Review of the resident's electronic medical record revealed that a self-administration evaluation had been completed, which indicated the resident was not able to self-administer medications. Additionally, there was no physician order authorizing the resident to self-administer his medications, as required by the facility's policy. The DON confirmed both the lack of a physician order and the evaluation's findings. Staff interviews further indicated uncertainty about the resident's assessment status and the practice of leaving medications in resident rooms.
Failure to Complete Required Smoking Risk Assessments for Resident with Smoking-Related Injury History
Penalty
Summary
The facility failed to implement its smoking policy for a resident with a known history of smoking-related burns and mental health conditions, including paranoid schizophrenia. The resident's care plan required staff supervision during smoking, use of safety equipment such as a cigarette extender and protective apron, and storage of smoking materials in a locked area. Despite these interventions, the facility did not complete required smoking program evaluation assessments at admission, readmission, quarterly, and after hospitalization, as mandated by their policy. Specifically, there were no quarterly assessments between December 2023 and August 2024, and no assessment was completed upon the resident's return from hospitalization. Interviews with staff revealed confusion and inconsistency regarding responsibility for completing smoking risk assessments. Some staff believed floor nurses were responsible, while others stated that only the DON or a specific RN completed them. The EMR system did not automatically prompt for these assessments, contributing to missed evaluations. Staff were aware of the resident's need for supervision and the storage of smoking materials, but the lack of timely and consistent assessments represented a failure to ensure adequate supervision and accident prevention as required by facility policy.
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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 Pierre
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avera Maryhouse Long Term Care | 0.1 mi | — | 14 | 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.