Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Fountain Springs Healthcare during CMS and state inspections, most recent first.
A resident who had recently fallen and been re-evaluated by PT was care-planned to be transferred with a stand aid lift, and this requirement was documented on the care sheet used by staff. Despite this, a CNA transferred the resident from a commode to a bed using only a gait belt and pivot transfer, after which the resident reported increased knee pain and received pain medication. Staff interviews confirmed that care sheets were the primary tool for communicating transfer status and that they were expected to follow them, but the facility could not provide a written policy on following care plans or using mechanical lifts, even though CNA duties required adherence to the plan of care and facility processes.
A resident admitted after a right tibia fracture repair, requiring non-weight bearing status and mechanical lift transfers, did not have a baseline care plan completed within 48 hours as required. Instead, staff relied on daily care sheets, and a transfer was performed using a slide board rather than the mechanical lift, causing the resident pain. The facility lacked a specific policy for baseline care plans, and key interventions were not added to the care plan until several days after admission.
A resident with dementia exited the facility unsupervised after her Wander Guard was removed and not replaced, with staff inaccurately documenting its presence. In a separate event, another resident's wheelchair was not properly secured during transport, resulting in injury when the chair tipped. Both incidents involved staff failing to follow safety protocols, placing residents at risk.
A resident reported to an LPN that a CNA had used inappropriate language, gestures, and a phone to take pictures and record her, and had stayed in her room despite being asked to leave. The incident was discussed among nursing staff and documented, but was not reported to the administrator, law enforcement, or state health authorities, and no investigation was initiated at the time. The allegations were only formally investigated and reported after the resident repeated them during a discharge follow-up call, at which point the CNA was terminated following validation of verbal abuse.
A resident with specific dietary needs choked on improperly prepared food and later died after staff failed to follow emergency protocols. The resident, who required a minced and moist diet, was served breaded cod that was not prepared correctly. Staff were confused about emergency procedures, delaying necessary interventions, and CPR was performed despite the resident's DNR status.
A CNA did not follow the manufacturer's instructions and the resident's care plan when using a standing frame mechanical lift, leading to a fall. The safety buckle was released while the resident was in the lift, but no injuries were reported.
Failure to Follow Care-Plan Transfer Method Using Mechanical Lift
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transferred according to her care plan and care sheet, specifically regarding the use of a stand aid lift. After a fall on 1/11/26, the resident, who had previously transferred with one-person assist and used a walker, began experiencing significant leg pain and was evaluated in the emergency room. Following this event, physical therapy re-evaluated her on 1/13/26 and recommended use of a stand aid lift for safe transfers, and this transfer status was reflected on her care sheet, which staff were expected to follow. Despite these updated transfer instructions, on 1/14/26 a CNA transferred the resident from the commode to the bed using only a gait belt and a pivot transfer instead of the ordered stand aid lift. The CNA later admitted to not using the stand aid lift as indicated on the resident’s care sheet. After this transfer, the resident complained of increased pain in her left knee, and the CNA notified the nurse, who provided pain medication. The incident was subsequently reported by physical therapy staff to the administrator and DON after the resident described the transfer and associated pain. Interviews and record review showed that staff were expected to provide care based on information in the resident’s care sheet, which included transfer status and other care needs, and that these care sheets were updated daily by management. Staff, including CNAs and nursing staff, confirmed that changes in a resident’s condition were to be communicated so that care sheets could be updated, and that new admissions were verbally reviewed and then formally assessed by PT for safe transfer recommendations. The facility was unable to provide a written policy for following residents’ care plans, using mechanical lifts, or transferring residents, even though the CNA job description required care consistent with the plan of care and facility policies and processes.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a recently admitted resident who had undergone a right tibia fracture repair and was non-weight bearing on her right leg. The resident required transfers using a full body mechanical lift, as indicated in her care plan and admission notes. However, the baseline care plan was not completed until several days after admission, and key interventions regarding her non-weight bearing status and transfer method were not added until seven days post-admission. On the evening following her admission, the resident reported to her daughter that a staff member was rough and rushed during a transfer to bed, which was performed using a slide board instead of the required mechanical lift. Although the resident was not injured, she experienced pain during the transfer and expressed a preference not to be cared for by the involved staff member. Staff interviews revealed that care sheets, which are updated daily, were used to guide care in the absence of a completed baseline care plan, but the official care plan outlining specific needs was not available to staff within the required timeframe. The facility did not have a policy specifically addressing baseline care plans and referenced federal requirements for developing and implementing such plans within 48 hours of admission. The DON confirmed that the baseline care plan was not completed as expected, and the responsible RN acknowledged that the care plan was not finalized at the time it was offered to the resident and her representative. This lapse resulted in staff relying on daily care sheets rather than a comprehensive, person-centered baseline care plan to guide immediate care needs.
Failure to Prevent Accident Hazards and Ensure Resident Supervision
Penalty
Summary
A resident with dementia and severely impaired cognition, who was at risk for wandering and elopement, was required to wear a Wander Guard device on both her wrist and wheelchair to prevent unauthorized exit from the facility. On one occasion, a staff member opened the entrance door for a visitor, and the resident was able to exit the facility undetected. The root cause was that an overnight shift nurse had removed the resident's Wander Guard prior to a medical appointment and failed to document its removal or communicate this to the day shift nurse. Upon the resident's return, the Wander Guard was not replaced, yet nursing staff continued to document that the device was present and functioning, despite it not being worn. In a separate incident, another resident was being transported by a facility-operated bus when the transport driver failed to secure the resident's wheelchair with the required floor straps. During the trip, the wheelchair tipped, causing the resident to hit her arm and sustain a scrape. The transport driver acknowledged not securing the wheelchair and only did so after the incident occurred. The driver had previously completed competency training for loading wheelchair passengers. Both incidents involved failures by staff to follow established safety protocols, including proper use and documentation of safety devices and adherence to transport safety procedures. These lapses resulted in residents being placed at risk for harm or injury due to inadequate supervision and failure to eliminate accident hazards.
Failure to Promptly Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to promptly investigate and report allegations of abuse involving a resident. On 12/29/24, a resident reported to an LPN, who was not assigned to her care that day, that a CNA had stayed in her room despite being asked to leave, used inappropriate language and gestures, and used a phone to take pictures and record her. Another staff member, a CNA, was also informed by the resident that the CNA in question had been disrespectful during personal care. The assigned RN, after being notified, went to the resident with two other staff members to discuss concerns, but the resident stated she had no concerns at that time. The CNA who received the complaint wrote a statement about the incident. The RN and LPN contacted the assistant director of nursing (ADON) to report the incident. The RN reported that the resident was having behaviors toward staff, while the LPN mentioned the resident's concerns about a CNA but did not provide specific details. The ADON instructed them to document the interaction and to ensure the staff member in question did not provide care to the resident. The following day, the director of nursing (DON) reviewed the progress notes and asked the social services director to speak with the resident, but no further information was obtained. Despite these actions, the incident was not reported to the administrator, law enforcement, or the state health department, and no formal investigation was initiated at that time. It was not until a discharge follow-up call several weeks later that the resident repeated the allegations, prompting the administrator to initiate an investigation and report the incident to the appropriate authorities. The subsequent investigation validated the allegation of verbal abuse, and the CNA involved was terminated. The delay in investigation and reporting constituted a failure to ensure that allegations of abuse were promptly addressed as required.
Failure to Follow Diet Order and Emergency Protocols Leads to Resident's Death
Penalty
Summary
The provider failed to ensure a physician-ordered diet was followed for a resident, leading to a choking incident during a meal service. The resident, who had a physician's diet order for regular texture with mildly-thick liquid consistency and minced and moist meats, was served breaded cod that was not prepared according to these specifications. The dietary manager confirmed that the cook did not process the fish correctly, which contributed to the resident's choking. During the incident, the resident was being fed by her visiting sister when she began to choke. Staff attempted to provide emergency medical intervention, including abdominal thrusts and CPR, but these efforts were not timely or appropriately executed. The resident, who had a DNR order, became unresponsive and passed away after emergency medical personnel arrived and took over the chest compressions. Interviews with staff revealed confusion and lack of clarity regarding the execution of emergency procedures. A CNA present during the incident did not perform abdominal thrusts due to uncertainty about her authority to do so, and a certified medication aide delayed performing abdominal thrusts until the resident was moved to another location. Additionally, the assistant director of nursing directed CPR to be performed despite the resident's DNR status, highlighting a breakdown in communication and protocol adherence.
Improper Use of Mechanical Lift Leads to Resident Fall
Penalty
Summary
On 4/29/24, a certified nursing assistant (CNA) failed to adhere to the manufacturer's instructions and the resident's care plan while using a standing frame mechanical lift. The CNA released the safety buckle while the resident was in the lift, resulting in the resident falling. Fortunately, the resident did not sustain any injuries from the fall.
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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 North | 1 mi | — | 2 | 0 |
| Avantara Mountain View | 1.9 mi | — | 5 | 0 |
| Good Samaritan Society - St Martin Village | 2.5 mi | — | 0 | 0 |
| Avantara Saint Cloud | 2.5 mi | — | 6 | 0 |
| Avantara Arrowhead | 3.2 mi | — | 20 | 0 |
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